Arthroscopy in patients with recalcitrant retropatellar pain syndrome

The purpose of this study was to determine the arthroscopic findings in patients with recalcitrant retropatellar pain syndrome (RPPS) and correlate them with the patient's long-term clinical course. All patients undergoing arthroscopy for recalcitrant retropatellar pain syndrome were evaluated. Patients were excluded from the study if there was any history consistent with a meniscal or cruciate injury or if they had previously had knee surgery. Long-term follow-up was obtained in 41 of 81 patients (51%) (range, 24 to 73 months; mean, 51 months). The arthroscopic findings were recorded, and the status of chrondral surfaces graded and correlated with clinical ratings, which utilized a modification of the Insall rating system. Debridement of cartilage irregularities was performed routinely. At follow-up, nearly equal numbers of patients improved, stayed the same, or got worse. No correlation was seen between the findings at arthroscopy and the long-term results. Debridement of cartilage lesions was not found to be beneficial as a treatment modality. Missed intra-articular pathology was found at arthroscopy in only two (4%) of the 81 patients. Based on this study, conservative treatment remains the treatment of choice.

Improved results with the "inverted T" modification of the Bristow procedure

The results of two modifications of the Bristow procedure in 21 patients were compared an average of 53 months after surgery. Twelve patients had an "inverted T" modification (group T) and nine patients had May's modification (group M). Recurrence rates and functional limitation were determined, as well as range of motion, pain, and apprehension with abduction and external rotation. Preoperative instability was classified according to the method of Protzman. Surgical outcome was graded using the rating scale devised by Rowe in 1978. There were no postoperative dislocations. Overall results were 16 excellent, three good, one fair, and one poor. All 12 patients in group T had an excellent result. In group M, there were four excellent, three good, one fair, and one poor result. Clinical score was 95 in group T and 75 in group M. Pre- and postoperative external rotation at 90 degrees abduction were 91 and 89 degrees in group T, and 99 and 77 degrees in group M.

The Bankart repair illustrated in cross-section. Some anatomical considerations

The Bankart repair for chronic anterior shoulder instability effectively addresses the pathologic components responsible for repeated dislocation or subluxation. However, contrary to popular belief, the Bankart repair does not precisely restore the premorbid anatomy. The capsule is reattached to the boney rim of the anterioinferior glenoid deep to and lateral to the torn cartilagenous labrum, thus excluding the labrum from the joint anteriorly. This was demonstrated by cross-sectional cadaver dissections performed to illustrate this complex surgical anatomy to orthopaedic residents in training. In addition, when correlated with double-contrast computerized axial tomography, we noted five predominant patterns of anatomical lesions which by common use have been collectively termed the "Bankart lesion." These are: 1) the rare "classic" Bankart lesion in which the cartilagenous labrum and capsular origin are torn from the glenoid rim; 2) the capsule stripped from the scapular neck and the labrum detached from the glenoid rim remaining fixed to the overlying capsule; 3) the capsule stripped from the scapular neck and the labrum separated from the glenoid rim, but separately; 4) the labrum abraded away and no longer radiographically detectable; and 5) glenoid rim fracture.

Chymopapain chemonucleolysis versus surgical discectomy in a military population

From 1983 to 1987, 100 consecutive patients with lumbar herniated nucleus pulposus were treated with either chymopapain chemonucleolysis (51 patients) or surgical discectomy (49 patients). The chymopapain-treated group was followed for an average of 16 months and the surgically treated group was followed for an average of 12 months. All patients had to be candidates for both procedures and were grouped for therapy based on their preference. The groups were similar in military duty status, history, age, gender, duration and character of symptoms, physical findings, and computed tomography/myelogram results. Satisfactory outcomes were achieved in 40 of 51 (78%) chymopapain-treated patients and in 39 of 49 (80%) surgically treated patients. Seventy-eight percent of the chymopapain group and 79% of the surgery group ultimately returned to full military duty. Of the nine initial chymopapain failures, eight were successfully treated with surgical discectomy. There were fewer complications, 4% versus 10%, in the chymopapain group. The authors now consider chemonucleolysis as the final conservative measure prior to surgery, rather than an alternative to surgical discectomy.

Arthroscopic treatment of transchondral talar dome fractures

Fifteen cases of transchondral talar dome fractures treated arthroscopically at the Naval Hospital in Oakland, California, were reviewed. Roentgenograms and results from clinical examination were assessed preoperatively and at regular intervals postoperatively. Clinical followup of 18 months was obtained in all cases (range, 18 to 36 months; mean, 26 months). All lesions were treated with arthroscopic excision of fragments with abrasion and/or drilling of the remaining crater. There were nine excellent results, four good, one fair, and one poor. There were no complications. Results of arthroscopic treatment compare favorably to those of open arthrotomy.

The natural history of conservatively treated partial anterior cruciate ligament tears

Twenty-five patients with arthroscopically proven partial ACL tears were reviewed. All patients underwent examination under anesthesia and arthroscopy following an acute injury to a previously normal knee. The percentage of tear was estimated during arthroscopy. Postoperatively, patients were treated with early motion and hamstring strengthening. Weightbearing and quadriceps rehabilitation were delayed. A detailed rating of symptoms and function was performed at a minimum of 18 months after injury, using a modification of the AOSSM ACL follow-up form. Neither the estimated percentage of ligament tear, length of followup, nor age at time of injury significantly correlated with clinical score at followup. Thirteen patients underwent partial meniscectomy at the time of original arthroscopy. Their clinical outcome was not different from those without meniscectomy. Two patients (8%) underwent ACL reconstruction 8 and 64 months after injury, respectively. Overall results were judged as excellent (28%), good (32%), fair (24%), and poor (16%). Only 44% were able to resume sports at their preinjury level, and 72% had activity-related symptoms.

Scapular osteomyelitis. An unusual complication following subacromial corticosteroid injection

Impingement syndrome is a common disorder of the shoulder. Most patients respond to conservative treatment consisting of rest, ice/heat, anti-inflammatory agents, and physical therapy. Subacromial corticosteroid injection may be used when other forms of conservative treatment fail. A case is reported involving a 29-year-old man who developed scapular osteomyelitis following subacromial corticosteroid injection. Successful treatment consisted of surgical debridement followed by a combination of intravenous and oral antibiotic therapy. Strict adherence to aseptic technique is emphasized for performing subacromial corticosteroid injection.

Evaluation and treatment of chemonucleolysis failures

Fifty patients underwent chemonucleolysis for the treatment of lumbar disk herniations unresponsive to conservative therapy. In patients treated with chymopapain, unrelieved sciatica was the most common cause of clinical treatment failure. Eight patients (16%) experienced no relief or only a transient reduction in their radicular symptoms following chymopapain injection. All eight patients were clinically reevaluated and underwent repeat neuroradiographic studies. Computed axial tomography and lumbar myelography demonstrated persistent nerve root compromise at the level of the injected disk space. Open diskectomy was performed in all eight cases. Postoperatively, seven patients noted complete resolution of their radicular symptoms; one patient had intermittent low back and leg pain following surgery.

Thoracolumbar needle biopsy

Utilizing radiologic C-arm control, percutaneous needle biopsy of the spine may be performed safely at the T11 through L5 levels. Its main advantage is the avoidance of performing an open surgical biopsy; however, it is an exacting technique and, even when done properly, the procedure may result in nondiagnostic tissue.

Triplane fracture of the distal tibial epiphysis. Long-term follow-up

The cases of twenty-three patients in whom a triplane fracture had been treated at the Naval Hospital, Oakland, California, between 1974 and 1985, were reviewed. The anatomical configuration of the fracture was confirmed in fifteen patients. Eleven of the fifteen patients had a three-fragment fracture. Plain radiographs alone did not accurately demonstrate the configuration of the fracture. Twenty patients were asymptomatic when they were evaluated eighteen to thirty-six months after the injury, but only eight of fifteen patients were asymptomatic when they were evaluated thirty-eight months to thirteen years after the fracture. Residual displacement of two millimeters or more after reduction was associated with a less than optimum result unless the epiphyseal fracture was outside the primary weight-bearing area of the ankle.

Bilateral anterior and lateral compartment syndromes in a patient with sickle cell trait. Case report and review of the literature

Bilateral, exercise-induced compartment syndrome occurred in the legs of a 19-year-old black man with sickle trait. Necrosis in the anterior and lateral compartments was so severe that subtotal debridement was ultimately required. Bilateral tibial compartment syndrome is a rare condition. Its occurrence is usually associated with underlying systemic disorders. The authors suggest that sickle cell trait played a role in this patient's dramatic course.

Arthroscopic treatment of acute patellar dislocations

Twenty-nine patients treated with arthroscopy alone for acute patellar dislocation were reviewed. All had a significant traumatic episode with hemarthrosis in a previously asymptomatic knee. Clinical follow-up averaged 25 months (range 5-64 months). Fifteen patients had concomitant percutaneous lateral release (LR). Significant-sized osteochondral defects not radiographically visible preoperatively were discovered in 40%. Fragments were excised and corresponding craters debrided or abraded. Additional intraarticular pathology discovered included two meniscal tears and one anterior cruciate tear. Overall excellent (E) and good (G) results were 83%. The recurrence rate was 14%, all of which occurred in the LR group. All recurrent dislocations occurred within 1-year post injury. The LR group had 73% G and E results compared with 93% in those without LR. Arthroscopy followed by immobilization was an efficacious approach to acute traumatic patellar dislocations in this specific group of patients. The addition of LR with early motion, however, detracted from the results.

Pigmented villonodular synovitis: a report of MR imaging in two cases

Although magnetic resonance (MR) imaging has been used to evaluate many musculoskeletal lesions, the MR appearance of pigmented villonodular synovitis (PVNS) has not been described in detail. The authors describe two cases of PVNS in the knee imaged with both computed tomography and MR. In both cases parts of each lesion had very low signal intensity on both short repetition time (TR)/echo time (TE) sequences and long TR/TE sequences. Other portions of both lesions had intermediate signal intensity (equal to or higher than that of muscle but lower than that of fat) on short TR/TE sequences and increasing signal intensity on longer TR/TE images. In one case, the lesion also had a cystic component that showed MR changes typical of complex fluid. The authors propose that the MR signal characteristics demonstrated in these cases may be explained by the unique tissue components of the lesion, particularly hemosiderin and fat.

Kienböck's disease

Kienböck's disease is an isolated disorder of the lunate resulting from vascular compromise to the bone. The symptoms include wrist pain, limited range of motion, and decreased grip strength. The diagnosis is made from characteristic changes seen in the lunate on radiograms of the wrist. The severity of the disease can be categorized by staging the degree of involvement. This is helpful in guiding the practitioner through the maze of treatment options. Initial treatment of Kienböck's disease is conservative and includes immobilization, analgesics, and/or anti-inflammatory medication. If symptoms are not relieved, then based on the degree of involvement, several surgical options exist that will provide a successful result. These include autogenous tendon replacement arthroplasty, revascularization, radial shortening, ulnar lengthening, limited intercarpal arthrodesis, and silicone replacement arthroplasty. Salvage procedures for Kienböck's disease include wrist denervation, wrist arthrodesis, and proximal-row carpectomy. Currently, we prefer immobilization for treatment of stage I Kienböck's disease. For stage II, a revascularization procedure may be attempted or ulnar lengthening/radial shortening done, particularly if there is significant negative ulnar variance. In stage III, replacement arthroplasty and/or limited intercarpal arthrodesis is our treatment of choice, and for stage IV, one of the salvage procedures is indicated.

Dercum's disease (adiposis dolorosa). A case report and review of the literature

Dercum's disease consists of multiple, painful lipomata and occurs in obese, postmenopausal women. A 52-year-old obese woman complained of multiple painful "lumps" in the extremities. The diagnosis of Dercum's disease (adiposis dolorosa) was established by excisional biopsy of four tumors. There is no effective treatment for this condition. Surgical excision, in this case, relieved the patient's symptoms locally, but after one year the painful lipomata had appeared at other sites. Case reports of this condition were not found in a review of the orthopedic literature.

The use of lumbar extension in the evaluation and treatment of patients with acute herniated nucleus pulposus. A preliminary report

Many patients with acute herniated nucleus pulposus can be expected to resolve their conditions with conservative management. To date, however, no reliable sign has been described in the literature that can predict which patient will respond. This report shows that the ability to achieve normal lumbar extension represents such a sign. Of 67 patients who met the criteria for inclusion in the study, 35 patients were treated without operation; 97% were able to achieve normal lumbar extension within three days of admission to the hospital. Thirty-two patients underwent laminotomy and discectomy because they failed to improve with conservative measures. Of these patients, only two (6%) were able to achieve normal lumbar extension preoperatively. Furthermore, some of these patients responded so dramatically to extension therapy that the use of extension exercises as a therapeutic modality is recommended.

The Elmslie-Trillat procedure: evaluation in patellar dislocation and subluxation

The Elmslie-Trillat procedure for correction of patello-femoral malalignment was evaluated in 27 knees in 22 patients with an average followup of 42 months (minimum of 24 months). Preoperative and postoperative pain and activity levels were recorded for all knees. The quadriceps angle was recorded in 22 knees preoperatively and in 19 knees postoperatively. Good or excellent results were obtained in 81% overall and in 91% of those knees with patella alta. The postoperative quadriceps angle (Q-angle) correlated with the result. Correction of 10 degrees or less was always associated with a good or excellent result. In contrast, all patients with a fair or poor result had Q-angles at 15 degrees or greater. The preoperative Q-angle did not correlate with the eventual result. We concluded that inadequate medial displacement of the anterior tibial tuberosity may lead to unsatisfactory results and that this may be avoided by intraoperative measurement of the Q-angle; that significant distal advancement of the tibial tuberosity is not required in patella alta; and that correction of the Q-angle to 10 degrees or less correlates with a good or excellent result from the Elmslie-Trillat procedure for treatment of patella subluxation and dislocation.

Limb salvage procedure for neoplasms about the knee by spherocentric total knee arthroplasty and autogenous autoclaved bone grafting

Spherocentric total joint arthroplasty was performed for treatment of neoplasm in 15 patients. The average follow-up period was 30 months. In nine of the patients concomitant autoclaved autologous bone implants were also prepared from the resected specimens. The results were satisfactory in ten patients and unsatisfactory in five. One patient had an infection that required amputation. One patient with osteosarcoma had a recurrence at 20 months and was treated by amputation. Poor results were caused by stem failure in two patients and by component loosening in one patient. Total joint arthroplasty combined with autoclaved bone implantation is a useful limb salvage procedure for resected neoplasms about the knee.

Compression plate position. Extraperiosteal or subperiosteal?

Although compression plate fixation of diaphyseal long bone fractures is accepted treatment, surgical exposure and plate position in relation to the periosteum are controversial. Histologic, roentgenographic, and biomechanical methods were applied to investigate quality and chronology of healing in radial and ulnar fractures in adult dogs. Plate position was extraperiosteal in one limb and subperiosteal in the contralateral limb. There were no statistical differences in roentgenographic or histologic studies of healing between the two techniques, nor were significant statistical differences noted when comparing linear load, maximum load at failure, slope of the linear portion, energy absorbed to failure, stress, modulus of elasticity, strain at maximum linear load, strain at maximum load, and strain at failure. Thus, there was no appreciable difference in fracture healing between subperiosteal and extraperiosteal exposure with compression plate fixation of diaphyseal fractures in dogs. However, subperiosteal exposure is preferable because it is less likely to injure surrounding soft tissues.

Nitrous oxide analgesia for minor orthopedic procedures

The need for adequate analgesia to perform potentially painful procedures on our orthopedic patients is of paramount importance. Narcotics and tranquilizers, although effective, often cause prolonged somnolence lasting long after the orthopedic procedure is completed. Nitrous oxide, on the other hand, takes effect within minutes and its pharmacological effects subside rapidly upon termination of inhalation. The purpose of this study was to determine the effectiveness and safety of using nitrous oxide analgesia for minor orthopedic procedures. Thirty-seven patients were administered a 50% nitrous oxide/50% oxygen mixture. The orthopedic procedure was then performed followed by three minute nitrous washout with 100% oxygen. Twelve patients received conventional parenteral medications and were compared to the former group. Evaluation of the results following the administration of these two methods of analgesia revealed both to be relatively safe with the nitrous oxide having a significantly greater level of patient acceptance. At this medical institution it is now the preferred method of our orthopedic surgeons who routinely perform these procedures.

Kienböck's disease--update on silicone replacement arthroplasty

In a previous paper, early lunate silicone replacement arthroplasty (SRA) for Kienböck's disease was advocated because of poor results obtained in stage III disease. Since then, an additional 16 patients have been operated on. Thirteen had stage III disease, and 12 underwent successful SRA. This result is attributed to the modification in anatomical configuration and the improvement in the physical characteristics of the new high-performance silicone lunate implant. Because SRA gives good results in a high percentage of patients in stage III disease, alternative modes of therapy may be considered in stage I or stage II disease without jeopardizing the ultimate result from SRA in stage III disease.

Irreducible distal radioulnar joint occurring in a Galeazzi fracture - case report

This is a report of an irreducible distal radioulnar joint associated with a Galeazzi fracture. The irreducible dislocation of the radioulnar joint was not appreciated until 2 weeks following compression plating of the radius fracture. The extensor carpi ulnaris was found to be wrapped anteriorly about the ulnar border of the distal ulna and was trapped in this position by the displaced ulnar styloid. The patient was successfully treated with open reduction of the styloid fracture and temporary wire fixation.