Radiofrequency cervical zygapophyseal joint neurotomy for cervicogenic headache: a prospective study of 15 patients

The present study assessed the clinical efficacy of radiofrequency cervical zygapophyseal joint neurotomy in patients with cervicogenic headache. Fifteen consecutive patients with cervicogenic headache were treated and then assessed one week prior to treatment and, at short-term (8 weeks), intermediate (mean 8.8 months) and long-term (mean 16.8 months) follow-ups. The following were taken as outcome parameters: Visual Analogue Scale (VAS), 7-point Verbal Rating Scale (VRS), number of headache days per week and analgesic intake per week. The results of this study showed that radiofrequency neurotomy of the cervical zygapophyseal joints significantly reduced headache severity in 12 (80%) patients, both at short-term and long-term follow-up assessed by 7-point VRS. Mean VAS decrease was 31.4 mm (p < 0.001) and 53.5 mm (p < 0.0001) respectively in this period. The average mean number of headache days per week decreased from 5.8 days to 2.8 days (p = 0.001) and the average analgesic intake per week showed a reduction from a mean of 17.5 tablets to a mean of 3.4 tablets (p = 0.003). A definitive conclusion about the clinical efficacy of this treatment can only be drawn from a randomized controlled trial.

The role of anteromedial foraminotomy and the uncovertebral joints in the stability of the cervical spine. A biomechanical study

STUDY DESIGN

The biomechanical role of the cervical uncovertebral joint was investigated using human cadaveric spines. Sequential resection of cervical uncovertebral joints, including clinical anteromedial foraminotomy, was conducted, followed by biomechanical testing after each stage of resection.

OBJECTIVES

To clarify the biomechanical role of uncovertebral joints and clinical anteromedial foraminotomy in the cervical spine and their effects on interbody bone graft stability.

SUMMARY OF BACKGROUND DATA

Although the biomechanical role of the cervical uncovertebral joints has been considered to be that of a guiding mechanism in flexion and extension and a limiting mechanism in posterior translation and lateral bending, there have been no studies quantifying this role. According to results in quantitative anatomic studies, anatomic variations exist in uncovertebral joints, depending on the vertebral level, articular angulation, and relative height of the joints.

METHODS

Fourteen human functional spinal units at C3-C4 and C6-C7 underwent sequential uncovertebral joint resection, with each stage of resection followed by biomechanical testing. The uncovertebral joint was divided anatomically into three parts on each side: the posterior foraminal part, the posterior half, and the anterior half. The loading modes included torsion, flexion, extension, and lateral bending. A simulated anterior bone graft construct was also tested after each uncovertebral joint resection procedure.

RESULTS

Significant changes in stability were observed after sequential uncovertebral joint resection in all loading modes (P < 0.05). The biomechanical contribution of uncovertebral joints decreased in the following order: the posterior foraminal part, the posterior half, and the anterior half. Unilateral and bilateral foraminotomy most affected the stability of the functional spinal unit during extension, causing a 30% and 36% decrease in stiffness of the functional spinal unit, respectively. The effect was less in torsion and lateral bending. After sequential resection, there was a statistically significant difference between decreases in torsional stiffness at C3-C4 and C6-C7 (P < 0.05). The stiffness of the simulated bone graft construct decreased progressively during flexion and lateral bending after each foraminotomy (P < 0.05). Increased bone graft height of 79% returned stability to the preforaminotomy level.

CONCLUSIONS

This is the first study to quantitate the biomechanical role of uncovertebral joints in cervical segmental stability and the effect at each intervertebral level. The effect differs because of anatomic variations in uncovertebral joints. The major biomechanical function of uncovertebral joints includes the regulation of extension and lateral bending motion, followed by torsion, which is mainly provided by the posterior uncovertebral joints. This study highlights the clinical assessment of additional segmental instability attributed to destruction of the uncovertebral joints during surgical procedures or by neoplastic lesions.

Clinical natural history of the postsurgical cruciate deficient canine stifle joint: year 1

The aims of this prospective study were to investigate the associations and correlations between individual clinical features of osteoarthritis of the cruciate deficient stifle joint and to document the temporal changes in these features over a 13-month period following surgical treatment. Fifty-eight dogs with osteoarthritis of the stifle joint, secondary to cranial cruciate ligament deficiency, were examined before surgical treatment for cruciate deficiency and at one and a half, seven and 13 months after surgery. At each visit, clinical features were graded using four-point, discontinuous, ordinal grading (Likert) scales and intra-articular pathology was also scored in a similar fashion at arthrotomy. No attempt was made to construct an aggregate score because the relative importance of different disease features and the relationships between them were not understood at the time of writing. At entry, the relationships between background disease variables and clinical parameters were investigated as well as the relationships between clinical parameters and intra-articular pathology scores. Longitudinal analysis was performed to test for those features which showed significant change over the 13-month follow-up period. At entry, periarticular thickening and degree of crepitus were significantly correlated with disease duration. Several features showed significant change over the study period. Notably, the degree of quadriceps atrophy showed significant decrease from baseline scores at seven and 13 months while remaining different from normal, suggesting that a measure of quadriceps atrophy may be a useful measure of long-term outcome in this disease.

Orthopedic management of septic arthritis

The goals in the management of septic arthritis are joint decompression, joint sterilization, and preservation of joint function. Opinions on how these goals are best accomplished vary among medical disciplines. Although the literature supports both serial aspirations and arthrotomy as viable ways to treat pyarthrosis, most orthopedic surgeons prefer arthrotomy. There are advantages to surgical management, including more complete decompression, especially in infections characterized by thick, purulent fluid or loculations; a lower intra-articular bacterial count after lavage; the opportunity to perform a synovectomy; and no delay in cases that may be unresponsive to simple aspiration and antibiotics. Rehabilitation of the septic joint is paramount in preserving range-of-motion and cartilage protection. Although splinting and immobilization are necessary in treating acute infections, early range of motion is paramount in preserving long-term joint function.

Lateral approach for arthrocentesis of the distal interphalangeal joint in horses

OBJECTIVE

To determine anatomic landmarks for a lateral approach for arthrocentesis of the proximopalmarolateral aspect of the distal interphalangeal (DIP) joint in horses and the likelihood of entering synovial structures other than the DIP joint through this approach.

DESIGN

Prospective study.

SAMPLE POPULATION

Paired forelimbs of 8 cadavers and 12 horses.

PROCEDURE

Anatomic preparations were used to determine anatomic landmarks. Positive-contrast arthrography was used to determine which structures were entered.

RESULTS

Landmarks for the lateral approach included a depression in the proximal border of the lateral ungular cartilage and the palmar border of the middle phalanx. Use of the lateral approach for arthrography resulted in deposition of contrast material exclusively in the DIP joint in only 13 of 20 limbs, whereas use of the dorsal approach resulted in deposition of contrast material exclusively in the DIP joint in 20 of 20 limbs.

CLINICAL IMPLICATIONS

The lateral approach is an alternative to the conventional dorsal approach to the DIP joint in horses, however, inadvertent entry into adjacent synovial structures is a possible complication. The lateral approach provides an additional portal for through-and-through lavage and arthroscopic access to the palmar aspect of the DIP joint.

[Chronic instability of the proximal tibio-fibular articulation: hemi-long biceps ligamentoplasty by the Weinert and Giachino technique. Apropos of 3 cases]

PURPOSE OF THE STUDY

Recurrent dislocations of the superior tibiofibular joint are rare. We report three cases of Weinert and Giachino ligament reconstruction.

MATERIALS

From 1989 to 1994, two soccer players and one young girl (10 years old) presented recurrent dislocation of the superior TFJ. The mechanism was a direct trauma, and the type of dislocation was antero-lateral. These patients were free of tibial fracture, major ligament lesion of the knee, and neurologic symptoms (peroneal nerve injury). Pain was over the fibular head, mechanical and increased by jumping. A lateral "cracking" was present. Examination showed an antero-posterior mobility of the fibular head. X-ray showed horizontal proximal tibiofibular joint. M.R.I. eliminated a lateral meniscal pathology and collateral ligament injury.

METHODS

The biceps tendon was split longitudinally for approximately seven centimeters. The posterior one half was transected proximally and mobilized. Secondly, the free end of the graft was passed posterior to anterior through a tibial tunnel. Thirdly, the tendon was sutured to the anterior tibial periosteum under tension with the fibular head reduced.

RESULTS

Follow up at one year revealed that all the patients were active, free of dysfunction and laxity, with no further episodes of instability and no loss of ankle mobility.

DISCUSSION

The diversity of treatments reported for this rare dislocation led us to believe that none proved its superiority. Resection of the proximal end of the fibula involves extensive dissection and creates a risk for the peroneal nerve vacuum and a lateral laxity. Arthrodesis of the superior tibiofibular joint without fibular osteotomy leads ankle pain, instability and a loss of ankle mobility. This procedure may also be complicated by screw loosening or breakage or by stress fracture of the fibula at the screw site. Arthrodesis of the superior tibiofibular joint with fibular osteotomy avoids these risks, but is possible for pain in the diaphyseal resection during the first 6 post operative months. Weinert and Giachino procedure, using a portion of the biceps tendon to reconstruct the superior tibiofibular ligament successfully stabilizes the superior tibiofibular joint, preserves all physiological function of the fibula and avoids resection or arthrodesis complications.

CONCLUSION

Based on our experience with these three patients and on literature review, ligament reconstruction for recurrent dislocation of the superior tibiofibular joint gives stability and indolence, and avoids complications of resection and arthrodesis.

Diagnostic and surgical arthroscopy in osteochondrosis lesions

In the dog, as in man and the horse, arthroscopy has an important role in treatment of joint disease. In the shoulder, elbow, and stifle joints, surgical arthroscopy can and should replace the classical surgical methods of treating osteochondrosis lesions. In elbow and tarsocrural joint disorders, the diagnostic potentials of arthroscopy are evident. With the established techniques, not only can the lesions be diagnosed with accuracy, but they can also be treated within the same procedure, making arthroscopy the treatment of choice to deal with osteochondrosis lesions. Without a doubt, arthroscopy will play an important role in the understanding of the etiopathology of different joint diseases, especially within the elbow joint, where so many questions remain unresolved. The advantages of arthroscopy in the diagnosis and treatment of osteochondrosis have also encouraged other veterinary surgeons to adopt the technique. In the developmental stage of arthroscopy in the dog, a frequently expressed comment was that arthrotomy was as valuable and as easy (or easier) to perform as arthroscopy. Now that the advantages of arthroscopy have been demonstrated, the skepticism has changed into enthusiasm. The same evolution is noted with arthroscopy in both man and the horse.

Ununited anconeal process in the dog

Recent data suggest that the cause of ununited anconeal process (UAP) is an incongruous growth of the radius and the ulna, causing abnormal pressure on the anconeal process. The current recommendation for treatment of UAP is to perform an osteotomy of the ulna to relieve this pressure and thus allow the anconeal process to unite. The operation should be performed as early as possible, before secondary changes have developed. Prognosis with treatment is favorable, even in active and working dogs.

Arthroscopic removal of palmar/plantar osteochondral fragments (POF) in the metacarpo- and metatarso-phalangeal joints of standardbred trotters--outcome and possible genetic background to POF

A clinical material of 133 Standardbred horses with palmar/plantar osteochondral fragments (POF) in the metacarpo- and metatarsophalangeal joints were studied. All horses had their fragments removed with arthroscopic surgery. 102 of the horses were 3 years old or younger when surgery was performed. Anatomical localisations of the fragments were in agreement with earlier reports. There was no statistical significant difference in month of birth in the POF--group compared to the total population. Eighty % of the horses that had raced before surgery came back to racing. The racing performance relative to their contemporaries remained the same after the POF operation. 65% of the horses that had not raced before surgery raced after the operation. The breeding index BLUP (Best Linear Unbiased Prediction) was used to evaluate if the POF-horses differed genetically in racing ability from the total population. The average BLUP value of the POF group was 103.4 (+/- 0.65), while the mean BLUP value of the total population was 98.9. This difference was highly significant and indicated that these POF horses belonged to a selected group. A homogeneity test of allele frequencies in blood type systems was performed to evaluate if any genetic difference was persistent between POF horses compared to the total population. The statistical analysis of gene frequencies for alleles in blood type systems indicated a genetic discrimination in blood type systems D and Tf.

Comparison of radiography, magnetic resonance imaging, and surgical findings in dogs with elbow dysplasia

OBJECTIVE

To describe the magnetic resonance imaging (MRI) appearance of medial coronoid process and humeral condyle lesions in dysplastic cubital joints and to compare survey radiography and MRI for evaluation of fragmented medial coronoid process (FMCP) and lesions of the medial aspect of the humeral condyle (MAHC).

ANIMALS

18 dogs with elbow dysplasia.

PROCEDURE

Radiography of 22 cubital joints was performed. The 22 joints then underwent MRI. The scans were evaluated with regard to the shape and signal of the coronoid process; articular cartilage change, subchondral bone disruption of the MAHC. Surgical findings were used as the standard to calculate accuracy, sensitivity, specificity, and positive- and negative-predictive values for specific diagnosis of FMCP (free fragment) and lesions of the MAHC.

RESULTS

At surgery, 31.8% of the joints had FMCP (free), 36.4% had nondisplaced unmineralized coronoid process, and 27.2% had nondisplaced mineralized coronoid process. Eleven joints had lesions of the MAHC, and wear lesions were observed in 41% of the joints. On radiography, FMCP (free) was visualized in 9% of the joints and lesions of the MAHC were observed in 23%. MRI had the highest accuracy (95.5%), sensitivity (100%), and negative-predictive value (100%) for detection of FMCP (free), and had accuracy (91%), sensitivity (87.5%), specificity (92.5%), and positive (87.5%)- and negative (92.5%)-predictive values for detection of nondisplaced unmineralized coronoid process.

CONCLUSIONS AND CLINICAL RELEVANCE

Compared with radiography, MRI was useful for detection of nondisplaced unmineralized coronoid process; images consistently correlated with surgical findings. The technique is accurate and especially useful when radiographic findings are inconclusive.

Influence of blood transfusion on bactericidal activity of human leukocytes and sera against Yersinia enterocolitica and Salmonella typhimurium

Patients undergoing joint surgery and blood transfusion were studied. Serum and leukocyte bactericidal tests in vitro against Salmonella typhimurium and Yersinia enterocolitica were carried out preoperatively as well as on the 1st, 3rd and 7th days after the operation. The serum complement (C3 and C4) concentrations were determined at the same intervals. It was found that after blood transfusion the bactericidic activity of sera and the serum C3 complement concentrations were increased. In contrast the killing ability of leukocytes was suppressed.

[Definition of complex trauma and general management principles]

Complex joint trauma is a term reserved for specific and severe injuries that include two or more structural elements of the joint. These structural elements are the articulating bones, the major ligaments of the joint, the local soft tissue envelope and the neurovascular structures. Complex joint trauma has a high risk for complications and requires a special treatment algorhythm. A staged surgical protocol with initial soft tissue debridement, closed joint reduction and external fixation of the extremity followed by secondary reconstructive surgery after soft tissue recovery is suggested.

Orthopaedic surgery in hemophilic patients with human immunodeficiency virus

Patients registered at the author's hemophilia center between 1982 and 1994 were studied to establish whether major orthopaedic surgical procedures accelerate the fall of CD4 lymphocyte counts of patients with hemophilia who are infected with the human immunodeficiency virus, and whether patients who had surgery had different rates of development of acquired immune deficiency syndrome or death when compared with patients who did not have surgery. The patients were divided into four groups: Group 1, 22 patients who were human immunodeficiency virus positive undergoing orthopaedic surgery; Group 2, 89 patients who were human immunodeficiency virus positive not undergoing orthopaedic surgery; Group 3, 18 patients who were human immunodeficiency virus negative undergoing orthopaedic surgery; and Group 4, 135 patients who were human immunodeficiency virus negative not undergoing orthopaedic surgery. There was no significant difference between the rates of decline of CD4 lymphocyte counts for patients who were human immunodeficiency virus positive who underwent surgery when compared with human immunodeficiency virus positive patients who did not undergo surgery, nor was there any significant difference between the two human immunodeficiency virus negative groups. There were no significant differences in the rate of development of acquired immune deficiency syndrome or mortality rates between patients who had surgery and those who did not.

Use of antibiotic-impregnated polymethyl methacrylate in horses with open or infected fractures or joints: 19 cases (1987-1995)

OBJECTIVE

To evaluate the clinical efficacy of antibiotic-impregnated polymethyl methacrylate (PMMA) in horses with open or infected fractures or joints in which internal fixation or external coaptation devices were used.

DESIGN

Retrospective case series.

ANIMALS

19 horses in which antibiotic-impregnated PMMA was used as part of the treatment regimen.

PROCEDURES

Medical records of each horse were reviewed, and owners and trainers were contacted to provide additional information.

RESULTS

Musculoskeletal problems in these horses included 10 fractures of long bones, 2 comminuted phalangeal fractures, 5 joint injuries, and 2 chronically septic joints in which ankylosis was stimulated. Nine horses had open fractures, 8 had closed wounds and developed infection after internal fixation of fractures, and 2 had chronically septic joints. Bony union was achieved in 15 of 19 horses. Twelve horses were discharged from the hospital and survived long term. Gentamicin sulfate, tobramycin sulfate, amikacin sulfate, and cefazolin sodium were used in PMMA.

CLINICAL IMPLICATIONS

Use of antibiotic-impregnated PMMA provided high local concentrations of antibiotics and should be considered in the treatment of horses with open fractures and acute and chronic bone and joint infections.

Resource utilization and cost of care for rheumatoid arthritis and osteoarthritis in a managed care setting: the importance of drug and surgery costs

OBJECTIVE

To describe the frequency and costs of medical services for patients with osteoarthritis (OA) or rheumatoid arthritis (RA) in a managed care setting.

METHODS

Individual utilization records of medical and pharmacy services for OA and RA patients were obtained from a group-model health maintenance organization (HMO). Estimates were made for costs of drugs and medical services for arthritis from July 1, 1993 to June 30, 1994 using Medicare reimbursement schedules and average wholesale drug prices. Calculated rates for each population were expressed as counts of events or as dollars per person-year.

RESULTS

The average individual cost rate of arthritis-related care for 365 RA patients was $2,162 per year, and the total cost of RA care to the HMO was $703,053. Prescription medications accounted for 62% ($436,440) of the total cost of RA care, while ambulatory care accounted for 21% ($150,938), and hospital visits accounted for 16% ($115,674). With regard to 10,101 OA patients, the average individual cost rate was $543 per year, and total cost to the HMO was $4,728,425. Hospital care accounted for 46% ($2,170,890) of the total cost of OA care, medications accounted for 32% ($1,509,637), and ambulatory care accounted for 22% ($1,047,898).

CONCLUSION

RA care, in the setting of this study, was characterized by intensive treatment, especially frequent use of medications that were delivered to most patients. Although the cost of RA care per patient was high, cost to the managed care provider was relatively low, owing to the rarity of RA. OA care tended to be infrequent, and the largest component of cost was hospital care for a small proportion of patients (5%). Owing to the greater prevalence of OA, care of OA was nearly 7 times more costly to the managed care provider than was care of RA.

Surgical treatment of osteoarthritis

Surgical treatment of OA is appropriate when conservative therapy fails or is inadequate. The veterinary orthopedist's goals in treatment should be to alleviate pain, maintain function, and prevent or remove the potential for further degeneration of the joint. Currently, in veterinary surgery, THR and femoral head and neck excision are the primary treatments for OA of the coxofemoral joint. Other joints are treated primarily by arthrodesis or excision arthroplasty. Arthroscopy is proving to be a valuable tool in the diagnosis and treatment of OA, and total stifle and elbow replacement and cartilage resurfacing through chondrocyte grafting are on the horizon as potential treatment options.

2D and 3D finite element pre- and post-processing in orthopaedy

The present widespread tomographic techniques based on computed tomography (CT), magnetic resonance imaging (MRI) and automatic 2D and 3D reconstructions also involve numerous new points of view for planning surgical techniques in orthopaedy. These require efficient pre- and post-processing methods. By pre-processing and post-processing is meant both the generation of a finite element mesh that numerically models human joints and the visualization of the results obtained as required by the surgeon. Since the numerical reconstructions of human joints are based on the finite element approximation of contact problems assuming linear elasticity, the main goal of pre-processing is to generate triangular (2D) and tetrahedral (3D) meshes of objects with a 'reasonable' boundary-human joints. In our paper we restrict ourselves, for the sake of simplicity, to polygonal (resp. polyhedral) objects. The idea of preprocessing is based on the modified method of Delaunay Mangulalia and on the so-called relaxation technique. After the generation of the finite element mesh and after numerical simulation of surgical problems of orthopaedy, the results obtained as stress-strain fields, temperature, etc. may be visualized in a graphical form on the computer screen as well as on other media.

[New developments in joint surgery]

The treatment of joint injuries has seen a marked development in the last years. The surgical trauma of articular reconstruction was reduced and our deeper understanding of the mechanism of connective tissue healing influenced the rehabilitation program after joint injuries significantly. Indirect soft-tissue sparing reduction techniques can be applied to most joint fractures and improved fixation techniques using intraoperative fluoroscopy or arthroscopy allow to avoid vast exposures of the joint. The process of ligament healing requires joint movement and a certain stress to the healing tissue in order to achieve optimum scar strength, stiffness and remodeling. Immobilisation thus should be avoided completely after ligament injuries and certain lesions can be treated non-operatively with a high success rate (MCL rupture, ankle sprain, elbow dislocation). In other injuries, surgery should stabilize the joint thus allowing functional rehabilitation (cruciate ligament tears, shoulder dislocation).

Syndesmotic screw placement: a biomechanical analysis

At the present time, syndesmotic screw fixation is recommended when there is a tibiofibular diastasis, a Maisonneuve fracture, or syndesmotic instability after fixation of distal tibia-fibula fractures. The aim/purpose of this study was to demonstrate the optimal level of syndesmotic screw placement before creation of a Maisonneuve fracture. Legs of 17 embalmed cadavers underwent knee disarticulation. The legs were then dissected to expose the syndesmosis/interosseous membrane. The paired cadaver legs were tested in two groups. In group I (10 pairs), the left legs were tested without any syndesmotic fixation and the right legs were tested with the syndesmosis fixed at 2.0 cm above the tibiotalar joint. In group II (7 pairs), the syndesmosis in each left leg was fixed at 3.5 cm above the tibiotalar joint and the right leg syndesmosis was fixed at 2.0 cm above the tibiotalar joint. After ligament section and syndesmosis fixation, each leg was then jig mounted with transfixing wires through the proximal tibia and calcaneus. The ankle was placed in neutral with 15 degrees of pronation and a load of 150 pounds and a strain gauge anchored medially and laterally. The proximal tibia was internally rotated while the ankle was held fixed until syndesmotic, bony, or hardware failure occurred. Torsional force, the degree of rotation and the amount of syndesmotic widening were quantitated. Two-tailed t-test comparing no fixation with fixation at 2.0 cm indicated less syndesmotic widening with screw placed at 2.0 cm (P = 0.04). Two-tailed t-test comparing screw fixation at 2.0 cm and 3.5 cm indicated less syndesmotic widening with screw placed at 2.0 cm (P = 0.07). It would seem reasonable to place a syndesmotic screw at 2.0 cm above tibiotalar joint.

Reconstruction of the medial collateral ligament for tarsocrural luxation in the dog: a preliminary study

Seven cases of tarsocrural subluxation/luxation resulting from ruptures of the medial collateral ligament were treated by double prosthetic replacement. The technique was a revision of an earlier described method without the use of metallic implants. Six (100%) of six cases not involving additional joint fractures had excellent clinical results with minimal compromise to range of joint motion. In three (50%) of six cases where braided polyester sutures were implanted as the prosthesis, fistulating tracts developed. Drainage resolved with removal of the suture in each of these three cases, and two of the three proceeded to excellent results after replacing the braided suture with monofilament suture.

Racing performance in standardbred trotters with chronic synovitis after partial arthroscopic synovectomy in the metacarpophalangeal, metatarsophalangeal and intercarpal (midcarpal) joints

Chronic synovitis may cause recurring lameness in competing race horses. Forty-five standardbred horses with recurring lameness secondary to chronic synovitis were studied. Arthroscopic synovectomy was performed in 32 metacarpo-/metatarsophalangeal joints and in 28 intercarpal joints of horses that had previously been treated unsuccessfully with commonly used intraarticular medication The outcome of the synovectomy was evaluated by comparing racing performance before and after surgery. The synovial membrane was microscopically characterized as chronic synovitis of varying severity. Racing performance was expressed by racing results including average earnings/race, place 1-3, best time and racing index. Fourteen of 19 horses with chronic synovitis of the intercarpal joint performed at an equal or higher racing level after synovectomy. Twenty-one of 26 horses with lameness secondary to chronic synovitis in the fetlock joint had an equal or higher racing capacity after synovectomy. The results of this study indicates that arthroscopic synovectomy in combination with rest is an effective method in the treatment of chronic synovitis when conventional intraarticular medication has failed.

Palmaroproximal approach for arthrocentesis of the proximal interphalangeal joint in horses

A technique was developed for arthrocentesis of the palmaroproximal pouch of the pastern joint. The landmark for percutaneous puncture is a 'V' shaped depression formed by the palmar aspect of the proximal phalanx (P1) dorsally, an eminence associated with the attachment of the collateral ligaments to P1 and the middle phalanx distally and the insertion of the lateral branch of the superficial digital flexor tendon palmarodistally. Comparison of arthrocentesis between the palmaroproximal approach and the traditional dorsal approach in 8 cadavers and 8 horses demonstrated that the palmaroproximal approach was associated with less needle manipulation, greater injection volume (horses) and frequent synovial fluid flow.

Case report: radiation prevention of heterotopic ossification after bone and joint surgery in sites other than hips

Five patients were given single dose irradiation in an attempt to prevent heterotopic ossification after bone and joint surgery in sites other than hips. All patients were at risk for the development of post-operative heterotopic ossification. Two patients were treated with 6 Gy and three patients were treated with 7 Gy the day after operation. No complications were encountered. Post-operative heterotopic ossification did not develop in patients who received 7 Gy, whereas treatment failed in the two patients who received 6 Gy. Because this is a case report study, no conclusion could be made. Further investigation is needed to assess the efficacy of post-operative single dose irradiation in heterotopic ossification prophylaxis in sites other than hips in high risk patients.

Reported blood exposure rates and staff nurse satisfaction with a closed surgical drainage system

BACKGROUND

The purposes of this investigation were (1) to describe performance characteristics, incidence of exposure, and staff satisfaction with a closed drainage system, the Kendall Tru-Close, and (2) to compare performance, incidence of exposure, and satisfaction between the closed drainage system and a currently used surgical drainage system (the Hemovac).

METHODS

Subjects were 40 adult male and female patients who had undergone selective orthopedic joint surgery. Twenty patients received the Hemovac drainage system, and 20 patients received the Tru-Close drainage system. Data collection instruments included a patient demographic data form, a daily assessment form, a nurses' bedside survey (self-report), and a satisfaction questionnaire.

RESULTS

There were significantly fewer exposures with the closed drainage system when compared with the Hemovac system. An odds ratio of 5.09 indicated that the odds of exposure to fluids with the Hemovac system were five times greater than for the closed system. Nursing satisfaction scores were higher for the Tru-Close system than the Hemovac system for items that related to protection from exposure to self or environment. However, overall nursing satisfaction with the new device was mixed.

CONCLUSIONS

Although nurses liked the increased protection from exposure afforded by the Tru-Close drainage system, other patient management issues emerged related to the increased weight of the reservoir bag.

A secure arthroscopic knot

The proposed arthroscopic knot tying technique procedure is simple, easy to master, time saving, and the knot formed is not bulky. The initial tie loop holding capacity securely overcomes tension force between structures repaired. The completed know, secured with additional two throw square knot or with a three half-hitches incorporating the post switching and/or loop direction reversal, will fail by breakage rather than by slippage (for the most commercially available 0, 2/0, 3/0, absorbable and nonabsorbable, monofilament and braided sutures.

Arthroscopy in food animal practice

Arthroscopy can be an effective technique for diagnosis and treatment of various orthopedic disorders in cattle, including septic arthritis and osteochondrosis. Cost of equipment and surgery may be prohibitive for some individuals, yet the techniques of arthroscopic surgery are proven efficacious when applied to cattle. Arthroscopic techniques may also be quite useful in the evaluation and treatment of the same disorders in sheep, goats, and camillids. The technology remains the same and applicability rests with financial constraints and the physical aspects of specific species and joints. We speculate that arthroscopy would be quite useful for exploration and treatment of the larger joints and other selected joints of these species.

Suture anchor strength revisited

The rapid proliferation of suture anchors continues. Our prior report on the pullout strength of 14 different anchors is supplemented by a similar test conducted on 8 additional anchors. Comparative data on modes of failure and failure strengths (ultimate loads to failure) for these new devices are compared statistically with the previously tested anchors. In a fresh never-frozen porcine femur model, 10 samples of each of the additional anchors tested were threaded with stainless steel sutures and inserted into three different test areas (diaphyseal cortex, metaphyseal cortex, and a cancellous trough). Tensile stress parallel to the axis of insertion was applied at a rate of 12.5 mm/s by an Instron 1321 testing machine (Instron Corp, Canton, MA) until failure and mean anchor failure strengths calculated. The anchors tested were the Mitek G2 as a control, miniMitek, Mitek Superanchor, Mitek Rotator Cuff anchor (Mitek Products, Westwood, MA), Innovasive Devices Radial Osteal Compression device (Innovasive Devices, Hopkinton, MA), Arthrex Fastak (Arthrex Inc, Naples, FL), Arthrotek miniHarpoon (Arthrotek, Warsaw, IN), Orthopedic Biosystems PeBA 3 and PeBA 5 (Orthopedic Biosystems, Scottsdale, AZ), and AME 5.5 screw (American Medical Electronics, Richardson, TX). Failure mode (anchor pullout, suture eyelet cut out, or wire breakage) was generally consistent for each anchor type. The size of insertion hole is clinically important and each anchor's performance was evaluated as a function of its minor diameter or drill hole. For screw anchors, the larger the minor diameter of the screw, the higher the mean failure strengths in all three test areas (P = .001). However, larger drill holes for non-screw anchors resulted in lower mean failure strengths in cancellous bone (P = .03) and diaphyseal cortex (P < .005).

Total joint replacement and golf

Definitive characterization of the effects of golf on a total joint replacement remains elusive. However, from our study of active golfers and solicitation of the opinions of orthopedists who specialize in joint replacements, and from a careful review of the literature regarding exercise and total joint replacement, it appears possible for patients to remain active golfers with no significant increase in either symptoms or rates of revision of implants following total hip, knee, or shoulder replacement.

Fluid pump systems for arthroscopy: a comparison of pressure control versus pressure and flow control

We set out to compare two pump systems, one in which pressure alone could be controlled and the second in which pressure and flow could be controlled separately. Assessments were carried out by two observers independently. A variety of arthroscopic procedures were studied including arthroscopy of the knee, anterior cruciate ligament reconstruction, arthroscopy and acromioplasty of the shoulder, and arthroscopy of the elbow and ankle. We found that both systems used a similar amount of fluid. However, the operative time was significantly decreased with separate control of pressure and flow. This was related to the fact that there was better visualization and better technical ease with the latter pump. There was significantly less extravasation in the soft tissues. Therefore, based on our assessment, pumps that separately control pressure and flow are significantly better than pumps that control pressure alone. There is distinct advantage in less operative time, greater visualization, technical ease, and less soft tissue extravasation.

Management of penetrating joint injuries

A classification scheme for penetrating joint injuries is presented. Diagnostic techniques and treatment recommendations for managing penetrating joint injuries in small animals are described. Techniques used in human and equine patients are discussed for comparison.

Modified anterior approach to the cervicothoracic junction

STUDY DESIGN

This study reports the experience with four patients regarding a modified anterior approach to the cervicothoracic junction.

OBJECTIVES

This technique was evaluated with respect to extent of exposure, ease of technique, and postoperative morbidity.

SUMMARY OF BACKGROUND DATA

Previously reported anterior approaches to the cervicothoracic junction have described either full sternotomy resection of the left sternoclavicular junction or osteotomy of the clavicle. A simplified approach was chosen using a partial sternotomy, which has not been described previously for approaches to the spine.

METHODS

Four patients with metastatic disease, in the region of the cervicothoracic junction, required decompression and stabilization for palliation of symptoms. An anterior approach was required for decompression. A standard cervical approach was combined with a partial median sternotomy and transverse osteotomy through the synostosis between the manubrium and body of the sternum. In three patients, the left innominate vein was divided. Decompression and anterior stabilization were followed by posterior stabilization at an interval of 4 to 7 days.

RESULTS

This procedure was simple to perform, requiring little additional operative time for opening or closure. It provided excellent exposure from C3-T4. There was no associated morbidity related to the division of the manubrium or innominate vein.

CONCLUSION

Partial sternotomy combined with a standard cervical incision provides excellent exposure to the cervicothoracic junction from C3-T4. It is technically simple to perform and avoids the risk of injury to subclavian vessels inherent in resection of the clavicle or sternoclavicular junction. There is no additional morbidity associated with this approach.

[Treatment of burned joints and functional recovery]

From 1979 to 1990, 33 operations on 29 patients with joint burn were performed by early debridement and primary repair with myocutaneous flaps. As a result, 29 wounds healed by first intention. The healing rate of early operations performed within 10 days postburn was 95.2%, and that of the late operations delayed more than 10 days post-burn was only 75.0%. 31 among 33 joints (93.9%) recovered full range of movement, while the other 2 joints ended with only slight limitation of function. We suggest that the early debridement and primary repair with myocutaneous flap is the best choice for treatment of burned bone and joints.

[The trans-ulnar approach to the elbow joint]

A lateral approach to the elbow joint by ulnar diaphyseal osteotomy, first reported by Lenehan and Nunamaker (1982), is described. The ulna is transsected distally to the elbow joint. After the joint capsule, the caudal crus of the lateral collateral ligament and the annular ligament of the radius are dissected, the olecranon can be displaced medially. An optimal survey of the humeral condyle is guaranteed. The efficiency of this approach is demonstrated by a case report.

Traumatic avulsion of the ulnar collateral ligament of the IP joint of the thumb

We present a previously undescribed injury of avulsion of the ulnar collateral ligament of the thumb IP joint. Stress radiographs may be used to confirm the diagnosis in cases of clinical suspicion.

Arthroscopic removal of axial osteochondral fragments of the plantar/palmar proximal aspect of the proximal phalanx in horses: 119 cases (1988-1992)

Medical records from 119 horses that had undergone arthroscopic surgery for removal of axial osteochondral fragments of the palmar/plantar proximal aspect of the proximal phalanx were reviewed. Standardbred racehorses represented 109 (92%) of those affected. Ninety-three (78%) of the horses were < 3 years old. Gender distribution was consistent with that of the equine hospital population. Fragments most commonly were observed in the hind limbs (155/164; 95%), specifically, on the medial aspect of the left hind limb (72/164; 44%). Bilateral fragmentation occurred in 21 of 119 (18%) horses, and 15 of 119 (13%) horses had fragments in the medial and lateral aspect within the same joint. Fifteen (13%) horses had a concurrent osteochondritis dissecans lesion on the distal intermediate ridge of the tibia, and 30 of 119 (25%) had radiographic signs of osteoarthritis involving the centrodistal (distal intertarsal) and tarsometatarsal articulations. In 55 of 87 (63%) racehorses and in 100% of the 9 nonracehorses, performance returned to preoperative levels after surgery. Fragment numbers or distribution, concurrent osteochondritis dissecans lesions of the distal intermediate ridge of the tibia, or tarsal osteoarthritis were not significantly associated with outcome. Abnormal surgical findings, consisting of articular cartilage fibrillation or synovial proliferation, were significantly (P < 0.0001) associated with adverse outcome; these findings were documented in 31% of the 32 horses without successful outcome and in only 2% of the 55 horses with successful outcomes.

Headache due to an extra joint between head and neck

A girl, born in 1973, started having headache in preschool age. After a head trauma in 1985, there was a clear worsening of the headache, and the headache became chronic at around 14 years, making regular school attendance impossible. The headache was "symptom poor," bilateral-occipital, but with a clear left-sided preponderance and occasionally spreading to the forehead. The headache was always worst in the morning hours, easing up by noontime. Neck rotation to the right could provoke long-lasting exacerbations. Neck movement was restricted on rotation to the left. A sore bony structure was discovered on palpation just underneath the mastoid process of the left side. This proved to correspond to a bony "bridge" with an extra joint between the first vertebra on the left side and the skull, medially to the mastoid process that could be demonstrated on x-ray tomography and CT scanning. This bony bridge was removed surgically more than 2 years ago, and the pain disappeared on the day of operation and has not recurred in the intervening time. Such bony bridges have in the past been considered to be innocuous and not symptom producing. Although this may be the general rule, the present case tends to show that even to this rule, there are exceptions.

Comparison of the cranial and a new lateral approach to the femoropatellar joint for aspiration and injection in horses

The genual joint in horses is complex, making synovial fluid aspiration and injection of the femoropatellar joint difficult. Horses commonly have signs of resentment to needle penetration at this site. We compared the safety and efficacy of a new technique, using a lateral approach to the femoropatellar joint, with that of the standard cranial approach in 12 horses. A significantly greater amount of fluid was obtained with the lateral approach (2.0 +/- 0.5 ml, mean +/- SEM) than with the cranial approach (0.9 +/- 0.2 ml). Significant differences were not observed in color, nucleated cell count, RBC count, or total protein of the fluid. Mean articular cartilage injury score was significantly lower with the lateral approach (0.3 +/- 0.3), compared with that from the cranial approach (1.3 +/- 0.4). Only 8% of the joints (1/12) in which the lateral approach was used were injured, compared with 67% (8/12) in the cranial approach. The lateral approach yielded more fluid and was less likely to result in injury to the articular surface than was the cranial approach.

Surgical treatment of juvenile rheumatoid arthritis

There is no general agreement about the role of surgery in the treatment of juvenile chronic arthritis patients. It is very natural that in the case of the growing child, the surgical armament is limited to prophylactic procedures, and reconstructive operations are rather rare. In Finland, with a population of 5 million people, slightly less than 1,000 children under the age of sixteen suffer from juvenile chronic arthritis. Among these, about half need to be hospitalized every now and then. Our institution covers about 85% of hospital treatment. Consequently, most cases with severe disease necessitating surgery are treated in one hospital. The annual number of operations has decreased markedly during the last ten years due to the more aggressive and more effective medical as well as other kinds of non-surgical treatment. Despite the active use of local steroid injections, tenosynovectomy is still necessary. Joint synovectomies are carried out today, when necessary, mostly arthroscopically. Major surgery such as joint replacement is very rare in patients under the age of sixteen. If necessary, closure of the growth plates must be awaited, and special custom-made prostheses are used in most cases. The small bones and some particular deformities typical of JRA patients present special challenges to the surgeon's skill. Consequently, the conducting of these types of surgery should be centralized in specialized clinics.

The use of cannulated screws in musculoskeletal trauma. A review of surgical techniques

The use of minimally invasive techniques for the treatment of articular and periarticular fractures is becoming more popular, especially when formal open reduction and internal fixation is contraindicated because of associated soft-tissue compromise and swelling. Cannulated screws are frequently effective in these situations and can be inserted by way of limited open or percutaneous techniques in many cases. Accurate fracture reduction can be attained through insertion of cannulated screws over a guide pin, resulting in provisional stability of the fracture. In most instances, such methods of fracture reduction are adjunctive and require the addition of external fixation, limited internal fixation, and cast bracing or orthotic considerations. Applications of cannulated screw fixation in specific trauma injuries are discussed as are indications, contraindications, advantages, and disadvantages of such methods.

Simple excision of the trapezium for osteoarthritis of the carpometacarpal joint of the thumb

We have reviewed the results in 34 patients (39 operations) following simple excision of the trapezium for osteoarthritis of the basal joint of the thumb. The average age at operation was 57 years and the average follow-up was 6 years. All the patients were graded clinically and radiologically and were asked their opinion of the procedure. There was dramatic relief of pain following this procedure. Stability of the thumb was not compromised. When compared to the unoperated side, thumb length, thumb abduction and first web span were similar. There was a reduction in pinch strength (operated 8.1 k.p.a., non-operated 9.6 k.p.a.) and grip strength (operated 15.5 k.p.a., non-operated 19.5 k.p.a.) and an increase in MIP extension (operated 5.4 degrees, non-operated 2.9 degrees) following this procedure but the differences were not statistically significant. 11 patients (32%) had scar hyperaesthesia on testing but this was a clinical problem in two patients only (5%). Simple excision of the trapezium is a satisfactory procedure for the majority of patients with this disorder, but has a long post-operative rehabilitation period.

Joint resurfacing with cartilage grown in situ from cell-polymer structures

We tested the potential of a new technology developed in our laboratory to create new hyaline cartilage for resurfacing distal femoral joint surfaces of New Zealand White rabbits that had been surgically denuded of articular cartilage. We removed hyaline cartilage from the patellar groove of the distal femurs in 24 rabbits. Chondrocytes isolated from the excised cartilage of 12 of these rabbits (experimentals) were seeded onto synthetic biocompatible, biodegradable polymers composed of polyglycolic acid. The cells were labeled in vitro with a thymidine analog, BrdU (5-bromo-2'-deoxyuridine). After 1 week in vitro, the cell-polymer structures were implanted onto the denuded surfaces of 12 defects made in the hyaline cartilage of the contralateral knees of the experimental animals. Twelve control animals received either no implants or implants not containing cells on similar surgical defects. After 7 weeks, we found evidence of new cartilage growth in 11 of the 12 experimental animals and virtually no new cartilage formation in any of the animals in either control group. Immunohistochemical analysis demonstrated the presence of BrdU-labeled chondrocytes in representative specimens.

Arthroscopic removal of osteochondral fragments from the proximal interphalangeal joint of the pelvic limbs in three horses

Osteochondral fragments detected in the proximal interphalangeal joint in the pelvic limbs of 3 horses (2 Standardbreds and 1 Thoroughbred) caused joint enlargement and lameness. Fragments were removed by use of arthroscopy. Accurate placement of the arthroscope into the dorsal joint space was necessary to obtain an adequate view of the fragments. After surgery, 2 of the horses resumed racing without joint problems, and the third was in training to race. High-detail radiographs are necessary to detect osteochondral fragments in horses with joint enlargement or lameness localized to the proximal interphalangeal joint.

[Ultrasound imaging of soft tissue tumors of the extremities and para-articular soft tissue changes]

Valid preoperative imaging procedures are important in the diagnosis of soft-tissue tumours of the extremities due to their potential malignancy. The value of ultrasound regarding these tumours is still under controversial discussion. Hence, it was the aim of this retrospective study to examine the value of ultrasound in respect of these particular problems. Therefore, in 20 cases ultrasonography was compared with intraoperative findings and other imaging techniques. Finally ultrasonography is merely an "adjuvant" diagnostic procedure, because it does not precisely outline the anatomical topography is incomplete and differentiation from neural and vascular structures is not possible in all cases. In contrast, ultrasonographic description of the size of tumours demonstrates a good correlation when compared with intraoperative findings. In addition, ultrasound examination can help to improve preoperative diagnosis in cases when imaging with MRI and CT is disturbed due to already implanted metallic endoprosthetic components.