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Copyright
Acute
BY
CHAMP
L.
JR.,
M.D.t,
We
reviewed
the
follow-up
knees
had
instability
in thirteen
subjective
of 53.3
a positive
NORWOOD,
A.
clinical
records
and
patients
who
posterolateral
the diagnostic
and the effectiveness
of our
patients
who returned
for
evaluation
after
a mean
months.
Sixteen
external-rotation
for
thirteen,
the
jectively
five per
and
cent
any
results
chronic
of the seventeen
recurvatum
test;
instability.
in 85 per cent
in 77 per cent,
of these
patients
were
good
had
rated
objectively.
returned
Of
these
good
sub-
Eightyto athletic
activity
at their preinjury
level; the remaining
15 per
cent did not participate
in sports
activities.
A positive
posterolateral-drawer
test or external
rotation
recurvatum
test,
or both,
was diagnostic
of posterolateral
rotatory
instability.
The adduction
stress
test at 30 degrees
of knee fiexion
diagnostic.
Accurate
was usually
diagnosis
terolateral
rotatory
sult
in subjectively
Surgery,
positive,
but
and treatment
was not
of pos-
instability
in the acute stage
and objectively
acceptable
can reknee
AND
JACK
As the
of the posterolateral
C.
come
prominent
prognosis
compartment
of the
rotatory
the
and
jectively
the
(thirteen
Injury
complex
ternal
around
lateral
and
head
of the
During
the
diagnosed
acute
thirty-one
knees.
nosed
the
cruciate
resulting
laxity
of
patients,
subject
Fourteen
rotatory
Georgia
614
3 1995.
was
supported
Orthopaedic
Please
address
in part
Clinic,
tenderness
mild (1 +)
reprint
requests
to
Dr.
Baker.
Medicine
Columbus,
the
same
instability
to
with
ob-
in thirteen
pa-
for twenty-four
patients.
not
thirty-one
cast
clinical
in our
study
and
of
will
with
posterolateral
sustained
an in-
as evidenced
of induration
by the
and
a
of the limb
posterior
only a
treated
in either
splint,
and
functional
impairment,
level
to the remaining
operative
repair
rotatory
instability
records,
re-
during
.
seventhe
acute
Thirteen
of
follow-up
examination
53.3 months)
after surwere lost to follow-up
knee
to ligament
all
of
re-
of activity.
was limited
had
and
a
by
limb-raising
exercises.
None
reconstructive
surgery
for
posterolateral
relative
to
posterior
group
to have
these
patients
were available
for
twenty-four
to 1 15 months
(mean,
gical repair.
The other four patients
within
six months
after injury.
The
injury
the
However,
they showed
clinical
testing
and were
preinjury
study
who
from
diag-
latter
complex,
the presence
or
and
subsequent
The present
in
also
The
patients
thought
by immobilization
or
we
and
included
we
report.
were
full
1979,
instability
resulting
in thirteen
was
through
period
complex
of a later
quadriceps-setting
them
required
of
Sports
findings
rotatory
ligament
cylinder
stage
Road,
1970
lateral
non-operatively
mus-
Hamilton
often
to determine
followed
from
years
posterolaterally.
instability
on
popliteus
by the Hughston
6262
repair
were
jury to the arcuate
ligament
mechanism
of injury
and
findings
This work
Foundation,
Inc.
t Hughston
of early
posterolateral
of the
of the
ligament
and
ten
instability
patients,
arcuate
who
clinical
findings
Methods
however,
be the
teen
the
the
has
of acute repair
has not been
and
ligament
liga-
produce
posterolateral
rotatory
instability:
an exrotatory
subluxation
in which
the tibia
rotates
an axis in the intact posterior
cruciate
ligament’4.
seminars
instability
Materials
arcuate
collateral
muscle.
and
lateral
correlating
During
straight
both
fibular
gastrocnemius
to rotate
to 115 months.
the
the
by
knees)
ment,
and
be seen
Our purpose
in this study
was
features
of acute
posterolateral
effectiveness
of
cle,
GEORGIA
can be felt to be-
courses
pathological
posed
portion
can
plateau
as poor, the effectiveness
rotatory
instability
instability
operative
instability
tendoaponeurotic
tibia
of acute
previously.
diagnostic
to their
the
repair
been described
for posterolateral
documented
determine
COLUMBUS,
posteriorly.
turned
ligament,
the
tibial
in postgraduate
after
tients
M.D.t,
of Orthopaedics,
New Orleans
occurs,
Although
sidual
arcuate
HUGHSTON,
and the lateral
knee is provided
by both capsular
and non-capsular
ligaments
that form a single
functional
unit known
as the arcuate ligament
complex3’4
(Fig.
1). This complex
is comthe
of the Knee*
subluxation
externally
plaster
function.
The stability
Incorporated
Instability
M.D.t,
fifteen,
a positive
adduction-stress
test at 30 degrees
of
knee
fiexion;
and
twelve,
a positive
posterolateraldrawer
tst.
Associated
rotatory
instabilities
were
found
in ten of the seventeen
knees,
with anterolateral
rotatory
instability
being
the most frequent.
Two patients
had
associated
peroneal-nerve
palsy.
One
or
more
components
of the arcuate
ligament
complex
were
injured
in all seventeen
knees.
None
of the thirteen patients
who were
followed
required
subsequent
reconstruction
Joint
and
Orthopaedic
Clinic, Columbus,
and the Division
Section,
Tulane University
School of Medicine,
operative
notes
of seventeen
consecutive
were treated
by surgical
repair
for acute
rotatory
instability
in order to determine
of the
repair
and
of Bone
Rotatory
LYLE
From the Hughston
Sports Medicine
features
surgical
objective
by The Journal
Posterolateral
BAKER,
ABSTRACT:
983
sheets
stability
and
(records
diagrams
of
the
of the
operative
findings)
‘, and
operative
reports
of the seventeen surgically
treated
patients
were reviewed
to determine
the mechanisms
of injury,
diagnostic
features,
physical
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
ACUTE
POSTEROLATERAL
ROTATORY
INSTABILITY
OF
THE
615
KNEE
Middle One #{149}Thlrd,
Lot. Capsular LIg.
FIG.
The
arcuate
and operative
findings,
and associated
rected
particular
attention
to the results
eral drawer,
external
rotation
recurvatum,
stress
ligament
complex
injuries.
We diof the posterolatand adduction
tests24.
The
one
female
and
sixteen
male
patients
ranged
in
age
from
fourteen
to thirty-one
years
(average,
20.3
years).
The
interval
between
injury
and
examination
ranged
from zero to nine days (average,
1 .8 days);
six patients were seen on the day of injury.
The interval
between
injury
and surgical
repair
ranged
from two days to twelve
days (average, 5.9 days).
In six of the seventeen
patients,
the mechanism
of injury
pect
was a posterolaterally
of the proximal
part
tension;
in six,
the
external-rotation
force
three,
a motor-vehicle
hyperextension
athletic
activities
playing
directed
blow to the
of the tibia that caused
football.
thirteen
knees
VOL.
65-A,
instability.
NO.
5, JUNE
1983
showed
over the arcuate
ligament
a complete
peroneal-nerve
were found
in ten knees:
The
other
seven
in-
compalsy.
six had
instability;
three
and posteroanteromedial
and
knees
showed
side.
instability
only.
of the seventeen
knees
had
a positive
recurvatum
test;
fifteen,
a positive
test at 30 degrees
of knee
flexion;
and
a positive
Operative
posterolateral-drawer
Findings
Posterolateral
and
rotatory
test.
Surgical
instability
Management
was
diagnosed
at
the initial examination
our study.
Of these
rotation
recurvatum
of twelve
of the seventeen
knees
in
twelve,
six had a positive
externaltest; five, a positive
external-rotation
recurvatum
posterolateral
degrees
combined
anterolateral
and posterolateral
had combined
anteromedial,
anterolateral,
lateral
instability;
and one had combined
posterolateral
twelve,
mechanism
was
a hyperextension
with no direct
contact
involved;
in
accident;
and
in two,
a pure
were engaged
in
with eight of them
the lateral
posterolateral
Sixteen
external-rotation
adduction-stress
positive
or college
examination,
duration
and tenderness
plex.
Two patients
had
Associated
instabilities
from
medial
ashyperex-
injury.
Twelve
patients
at the time of injury,
high-school
At the initial
I
viewed
twelve
test
and
posterolateral-drawer
knees
also
had
test
a positive
drawer
test;
only.
Eleven
adduction-stress
and
one,
of
a
these
test at 30
of knee flexion.
Retesting
of these
twelve
knees
with
the patients
under
anesthesia
showed
that three
of the six knees
that
had had only a positive
external-rotation
recurvatum
test
also had a positive
posterolateral-drawer
test. In the remaining
nine patients
the findings
were
accentuated
but
did not change
when the knee was tested
with the patient
under
anesthesia.
In five knees
the posterolateral
rotatory
instability
was not diagnosed
at the initial
examination.
Four of them
had a positive
(2+)
adduction-stress
test at 30 degrees
of
knee flexion
at the initial
tenderness
and induration.
the mechanism
of injury,
examination
as well as lateral
These
findings,
coupled
with
prompted
further
examination
616
with
the
patient
showed
under
a positive
three
The
anesthesia.
of
them
had
a positive
knee
was
diagnosed
rotatory
a positive
instability,
test.
In all seventeen
routinely
examined
NORWOOD,
knees
then
test
and
test.
as having
based
test
instability
recurvatum
A.
posterolateral-drawer
on
an acute
the
at 30 degrees
ion and a positive
anterior-drawer
test
nally
rotated.
However,
examination
under
anesthesia
prior
to operative
teromedial
rotation
four
L.
recurvatum
initially
abduction-stress
JR.,
All
external-rotation
fifth
anteromedial
BAKER,
L.
C.
findings
of
of knee
flex-
with the tibia exterwith
the patient
repair
of the an-
demonstrated
a positive
test and a positive
(2+)
externaladduction-
knees,
the
and evaluated
space
initial
stress
teromedial
ploration
joint,
retinacular
incision.
of the suprapatellar
and the medial
capsular
and
through
a
cruciate
enteen
This
pouch,
lateral
extracapsular
lateral
ligament
was
an
was
an-
incision
allowed
the patellofemoral
compartments.
structures
‘
demonstrated
The
were
hockey-stick
knees.
The popliteus
knees:
eight
teen
and
intra-articular
through
lateral
evaluated
The
.
ex-
posterior
to be intact
in all sev-
musculotendinous
unit
patients
had an interstitial
tear
of the ligament
the
tibia.
knees:
seven
was torn in sixtear of the ten-
from
fibular
had
the femur;
collateral
a tear
of
the
and
three,
a tear
ligament
was
torn
ligament
from
the
from
in
fibular
was
torn
in its mid-substance
In each
of the seventeen
peroneal
nerve and performed
tients in whom
peroneal-nerve
preoperatively,
was
and
there
was
in two
knees.
in
the
nerve
but
it
intact.
Surgical
repair
tendons
to
by direct
sence
of periosteum,
paired
severe
direct
suture
through
by
suture
tendon
of the
possible,
sutures
passed
ligaments
accomplished
the periosteum
direct
in
suture
four
or popliteus
that
using
knees
primary
with
or, in the ab-
through
drill-holes
suture
lateral
of the
head
arcuate
of origin.
of
the interstitial
did
the
ligament
non-absorbable
involvement
tendon,
Therefore,
we reinforced
the
knee by proximal
advancement
attached
suture
whenever
Tears
within
the popliteus
musculotendinous
ligament,
fibular
collateral
ligament,
and
muscle
belly and tendon
of origin
were re-
by
However,
ligament
included
bone
either
in the bone.
unit,
arcuate
gastrocnemius
The anterior
cruciate
six had a mid-third
femur
holes
or tibia
in bone.
The lateral
peripheral
tear
not
correct
material.
of
the
injury
the
so
instability.
posterolateral
corner
of the
of a bone-block
with the
gastrocnemius
or popliteus
muscle
to the
and
advanced
by
ligament
mop-end
repaired
meniscus
and three,
was torn
in eleven
tear; three,
a tear of the
cast
with
sutures
through
was torn in four knees:
one had a
a tear in the body of the menis-
the
with
the
lower
knee
limb
flexed
was
placed
metal
the
prevented
external
which
would
have
of the hip and
adduction
stress
patients
began
on
walk
with
rotation
produced
the
strap
weight
lower
limb,
at the knee.
and
postoperative
crutches,
A pelvic
was incorporated
of the cast and
quadriceps-setting
first
in a toe-
to 60 degrees.
support
with a hinged
lateral
into the cast.
This supported
The
drill-
tear was repaired
by suture,
and the
tears within
their substance
were exmeniscus
had a peripheral
tear, which
Postoperatively
to-groin
day
limb-raising
and
non-weight-bearing,
were
by
able
the
to
second
postoperative
day.
Prior
to discharge
from
the hospital,
each patient
was fitted for a double-upright
brace
with a
free ankle and a dial-locked
hinged
knee.
Six weeks
after
surgery,
the cast was
with the lock adjusted
limb
in the
for an
worked
removed
to allow
brace,
additional
to regain
and the brace
was applied
60 degrees
of flexion.
With
non-weight-bearing
was
six to eight
weeks
active
extension
by
continued
while
the
strengthening
patient
the
quadriceps
muscle.
Once
there
was active
extension
to
within
15 degrees
of neutral
the patient
was allowed
to
bear full weight
in the brace,
which
was worn for two to
three
months
more.
All patients
were bearing
full weight
in the brace three months
after surgery
or sooner,
and had
gained
full extension
within
six months.
Results
The
thirteen
patients
who
returned
for
follow-up
evaluation
were graded
subjectively
and objectively
by established
rating
criteria
(Table
I). Subjectively,
twelve
knees
(85 per cent) were rated good;
one, fair; and none,
poor.
The
fair
combi
ned
anteromedial
in a man who had had a repair for
, anterolateral
, and posterolateral
rotatory
instability.
This
patient,
who
worked
for the
Forestry
Service,
had occasional
discomfort
when walking
in wooded
areas on uneven
ground
but had no symptoms
ofgiving-way.
At follow-up,
the knee was stable on examination.
arcuate
was
were
cus. The peripheral
three
menisci
with
cised.
One medial
was repaired.
knees
we explored
the
a neurolysis.
In the two painvolvement
was diagnosed
hemorrhage
HUGHSTON
C.
ligament
from the femur;
and two, a tear from the tibia.
We excised
the anterior
cruciate
ligament
in the six knees
with a mid-third
mop-end
tear.
The avulsions
from
the
the
ten
styloid
process
and three,
a tear from the femoral
attachment. The gastrocnemius
muscle
belly was torn laterally
in
four knees and its lateral
head was avulsed
from the femur
in two. The biceps
femoris
muscle
was avulsed
from its
tibial or fibular
attachment
in eight knees,
and the iliotibial
tract
J.
exercises
don and muscle
belly;
five, a tear from
the femur;
and
three,
a tear of the muscle
belly from the posterior
aspect
of the tibia.
The arcuate
ligament
was damaged
in seventeen knees:
eleven
patients
had an interstitial
tear; three,
a
The
knees:
AND
good;
result
Objectively,
three,
fair;
was
ten (77 per cent) of the knees
were
and none,
poor. In the three patients
a fair result,
extension
the contralateral
knee
rophy,
the
centimeters
thigh.
who
One
had
was to within
10 degrees
of that of
and there was residual
quadriceps
at-
circumference
(0.5
of
returned
to
these
rated
with
0.75
of
inch)
three
thigh
than
patients,
to playing
THE
the
less
1 .3 to
the
OF BONE
year
AND
1.9
of the opposite
a collegiate
football
JOURNAL
being
that
linebacker
after
JOINT
injury,
SURGERY
ACUTE
had
a
1+
posterolateral
knee
in which
Eleven
patients
drawer
test.
high-school
and college
had any interest
in sports.
brace
for
the
injured
exercised
required
stability
knee,
routinely
At the time
had
and
study,
the
knee.
was
time
However,
thirteen
The
had
knees
a
chronic
ity
in-
had
sub-
I
5.
that of the opposite
knee
No quadriceps
atrophy
extension
and
either
no
recurvatum
or
drawer
recurvatum
equal
to
..
I
+
more
=
less
than
than
ten
five
sequent
surgery:
one,
sion of an associated
operation;
plasty
another,
push-off
ence
tion
tion
of the patella
at five
suprapatellar
staple
lateral
in the
65-A,
NO.
5,
JUNE
five
to ten
relative
the
1983
staple
after
synovectomy
years
millimeters,
displacement
rotatory
acute
stage
sub-
instabil-
and
is often
not
examination
six
weeks
after
in-
The
iliotibial
band
was
injured
in only
two
and in both of them the band
on the lateral
tibial tubercle.
was
of the
not torn
of an intact
that
tears
iliotibial
the
band.
arcuate
The
same
ligament
from
mechanism
of
its fibular
inser-
can also tear the biceps
femoris
muscle
from its inseron the fibula.
Thus,
the area of the fibular
head must
at the
injury
arcuate
to the
time
of surgery
ligament
and
to identify
the
biceps
and
repair
femoris
mus-
condyle
and
one,
initial
surgery.
peroneal-nerve
related
of
Both
palsy
the
edge
only
when
local
to a
of
in-
of the parecovered
can rupture
the soft tissues.
We presently
use staples
to attach
bone to bone,
as in the advancement
of the
tendinous
chondro-
removal
because
and
to
Early in the series,
we often used staples
to reattach
to bone.
We have since discontinued
the practice,
partly
because
we had to remove
the staple
from two patients but primarily
because
it is not a satisfactory
means
of achieving
ligament
stability.
As the ligament
or tendon
repetitively
pulls on its bone attachment,
the staple’s
sharp
and excithe initial
and
for symptoms
plica;
femoral
tation
six years
after
tients
with
preoperative
completely.
VOL.
=
tibial
a partial
a follow-up
be explored
tendon
2+
of
posterolateral
in the
no
instability
cle.
removal
of a lateral
bursa
at four years
pathological
until
injury
millimeters,
millimeters
with
ligament
Although
the iliotibial
band
is often
considered
a
basic stabilizer
of the lateral
side of the
, the
surgeon
must realize
that marked
ligament
laxity
of the knee,
particularly
of the posterolateral
corner,
can occur in the pres-
recreational
activities
possible
Occasional
feeling
of giving-way
Aching
with vigorous
activities
Return
to preinjury
status
with mild limitations
=
However,
diagnosed
seventeen
knees,
from its insertion
Poor
I . No recreational
activities
possible
2. Frequent
giving-way
3. Pain with activities
of daily living
4. No return
to preinjury
activities
3+
femur.
results
for
pos-
recognized
until
it has
become
a chronic
problem.
For
example,
during
the time-period
covered
by this study,
more than 140 reconstructive
procedures
were performed
rhage.
1 . Limited
4.
subjective
procedures
acute
percentage
this structure
is often
not appreciated
initially
because
the
iliotibial
band is intact
and there is no noticeable
hemor-
Fair
2.
and
of the
in a high
It is important
to emphasize
the associated
involvement of the biceps
femoris
muscle
that occurred
in eight of
the seventeen
knees
included
in this study.
The injury
to
Poor
I . 2 + or 3 + posterolateral
drawer
or external-rotation
recurvatum
test
2. Swelling
3. Tenderness
4. Limitation
of motion
of more than 10 degrees
compared
with the
opposite
knee
3.
required.
is rarely
tected
jury.
I . 1 + posterolateral
drawer
test or I + external-rotation
recurvatum
test
2. No swelling
3 . No tenderness
4. Less than 10 degrees
of limitation
of extension
or of flexion
5. Less than three centimeters
of quadriceps
atrophy
with
objective
reconstructive
treatment
resulted
been hospitalized
for contusions.
The instability
was correctly
diagnosed
one month
after
injury
when
he complained
of giving-way
of the knee. The second
patient
had
been treated
non-operatively
for anteromedial
rotatory
instability
because
the posterolateral
instability
was not de-
or
Fair
Subjective
Good
I . No limitation
of activities
2. No giving-way
or difficulty
3. No pain
4. Return
to preinjury
activities
operative
instability
for disabling
, chronic
posterolateral
rotatory
instability.
Two
of these
procedures
were
performed
on patients
whom
we had seen initially
and had misdiagnosed.
One
had been
involved
in a motor-vehicle
accident
and had
CRITERIA
No clinical
instability
measured
by the posterolateral
external
rotation
recurvatum
test
2. No swelling
3 . No tenderness
Full
617
KNEE
rotatory
good
sequent
Objective
Good
4.
of
being
had
THE
described
terolateral
patients
for any
OF
Discussion
of follow-up.
three
INSTABILITY
only
patients
of the thirteen
procedures
RATING
the
football,
and two
No patient
required
none
TABLE
ROTATORY
after repair.
athletics,
in-
ten of the
at the
of our
reconstructive
of
This
instability
was demonstrated
had returned
to competitive
cluding
never
still
POSTEROLATERAL
a
origin
there
complex.
In recent
brace
ment
of the
is interstitial
years
we
gastrocnemius
injury
have
muscle
to
used
the
a long
less frequently.
We now reserve
for patients
who have required
lateral
head of the gastrocnemius
ligament
into this tendinous
and
structure.
that
arcuate
is done
ligament
double-upright
this form
advancement
of treatof the
suture
of the arcuate
When
the torn ar-
618
C.
cuate
ment,
further
treated
knee
L.
BAKER,
JR.,
L.
A.
NORWOOD,
ligament
complex
can be secured
to a bone attachthe scar tissue
produced
is sufficient
to prevent
stretching
and
subsequent
instability.
Patients
in this manner
cast to a bent-knee
range-of-motion
progress
posterior
exercises
mobilized
in the
cast
six
presence
limb
has
been
im-
weeks.
The reverse
pivot-shift
study,
since it was described
we believe
that
rotation
recurvatum
the
was not used
in this
recently.
Furthermore,
is merely
a modification
of the external
test. In the reverse
pivot-shift
test, the
it
posterior
reduces
subluxation
as the flexed
ternally
rotated.
of the lateral
tibial plateau
suddenly
knee is extended
and the tibia is ex-
In the
external
rotation
the posterior
subluxation
of the lateral
reduced
as the knee extends
but then,
recurvatum
iner
systematically
must
drawer
drawer
also
test
test,
ligament.
and
be
aware
observed
that
the
instability.
of
the
tibia
signifying
posterolateral-
drawer
test
posteriorcruciate
must
also
However,
femur
hand,
true
is often
external
on
rota-
misinterpreted
test.
Thus,
as
when
a
the knee should
is a posterolateral
cannot
emphasize
of having
an accurate
history
of the
and of fully appreciating
the sub-
a complete
knee
examination.
If there
with
the patient
to help to establish
is any
under
anesthesia
the diagnosis.
Conclusions
1 Posterolateral
rotatory
instability
results
from injury to the arcuate
ligament
complex,
caused
either
by a
blow to the anteromedial
aspect
of the proximal
part of the
.
tibia
while
the
knee
external-rotation
2.
is hyperextended
hyperextension
A positive
or by
a non-contact,
injury.
posterolateral-drawer
test
rotation
rotatory
formed
recurvatum
test is diagnostic
of
instability.
A positive
adduction-stress
with the knee at 30 degrees
of flexion
of this
instability,
be
performed
with the tibia in internal
rotation,
since a positive anterior
or posterior
drawer
test indicates
injury to the
posterior
cruciate
ligament4.
A positive
adduction-stress
test performed
at 30 de-
instability.
adduction-stress
enough
the importance
mechanism
of injury
examination
be performed
a positive
to the ligaments
of
may occur
in the
positive
adduction-stress
test is elicited,
be tested
further
to determine
if there
rotatory
component
to the laxity.
We
of
exam-
the
a positive
doubt,
should
The
rotatory
On the other
on
tleties
carefully.
posterior
rotatory
test,
can be confused
with
a positive
which
indicates
a tear of the posterior
Therefore,
of posterolateral
tibial plateau
is first
as the knee hyperex-
tends,
subluxation
recurs
and the tibia again rotates
externally.
The reverse
pivot-shift
test is only a gross indicator
of posterolateral
rotatory
instability
and is too painful
and
unreliable
to be useful
in examining
an acutely
injured
knee.
The diagnostic
tests for posterolateral
rotatory
instability
the posterolateral
drawer
test and the external
rotation recurvatum
test - are subtle
tests that must be performed
HUGHSTON
because
a positive
adduction-stress
test does not depend
true rotational
motion,
it is not diagnostic
of posterolateral
tion
sign”
only
J. C.
grees of knee flexion
denotes
an injury
the lateral
compartment,
and therefore
from a toe-to-groin
bentsplint and are begun
on
after
for
AND
3.
A
but
peroneal-nerve
posterolateral
4. With
posterolateral
rotatory
correct
rotatory
jectively
objectively
and
is not
or
external-
posterolateral
test peris suggestive
diagnostic.
palsy
instability.
diagnosis
instability,
acceptable
may
be
associated
with
and treatment
of acute
the result should
be subknee
function.
References
1.
2.
HUGHSTON,
H UGHSTON
Instability
,
J. C.: A Surgical
Approach
J . C . , and NoRwooD,
L .
of the
Knee.
Clin.
Orthop.
J. R.;
Ligaments.
to the
A
,
. ,
JR
147:
.:
Medial
The
and
Posterolateral
Posterior
Drawer
Ligaments
Test
and
of the Knee.
Clin.
External
Rotation
Orthop.,
91: 29-33,
1973.
Recurvatum
Test for Posterolateral
Rotatory
82-87,
1980.
3. HUGUSTON,
J. C.; ANDREWS,
CROSS,
M. J.; and M0SCHI,
ARNALDO:
Classification
of Knee Ligament
Instabilities
Part I. The Medial
Compartment
and Cruciate
J. Bone
and Joint Surg.,
58-A:
159-172,
March
1976.
4. HUGHSTON,
J. C.; ANDREWS,
J. R.; CROSS,
M. J.: and M0SCHI,
ARNALDO:
Classification
of Knee
Ligament
Instabilities
Part II. The Lateral
Compartment.
J. Bone
and Joint Surg.,
58-A: 173-179,
March
1976.
5. HUGUSTON,
J. C.; BOWDEN,
J. A.: ANDREWS,
J. R.; and N0RW00D,
L. A.: Acute Tears ofthe Posterior
Cruciate
Ligament.
Results
of Operative
Treatment.
J. Bone and Joint Surg.
62-A:
438-450,
April
1980.
6. JAKOB,
R. P.: HASSLER,
HEINZ;
and STAEUBLI,
H-U.:
Observations
on Rotatory
Instability
of the Lateral
Compartment
of the Knee.
Acta
Orthop.
Scandinavica.
Supplementum
191. 1981.
7. KAPLAN,
E. B.: Surgical
Approach
to the Lateral
(Peroneal)
Side of the Knee Joint.
Surg. . Gynec.
and Obstet.
.
104:
346-356,
1957.
,
THE JOURNAL
OF BONE
AND
JOiNT
SURGERY
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