The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction

To correlate clinical results after anterior cruciate ligament reconstruction with tunnel placement measured radiographically, we prospectively studied 128 patients who had arthroscopically assisted bone-patellar tendon-bone reconstructions. Patients with bilateral anterior cruciate ligament reconstructions, other significant knee ligament injuries, or those undergoing chondroplasty or meniscal repairs were excluded, leaving 42 patients. The relationship between radiographic tunnel position and clinical results was determined using the Lysholm score, KT-1000 arthrometer testing, the Tegner activity level, and the pivot shift and Lachman tests. Clinical results correlated positively with posterior femoral tunnel placement on lateral radiographs and negatively with excessive anterior tibial tunnel placement. Specifically, when femoral tunnels were placed at least 60% posterior along Blumensaat's line and tibial tunnels were at least 20% posterior along the tibial plateau, 69% of patients had good or excellent Lysholm scores and 79% had KT-1000 arthrometer maximum manual side-to-side differences of 3 mm or less. When the above criteria were not met, 50% of patients had good or excellent Lysholm scores and 22% had KT-1000 arthrometer maximum manual side-to-side differences of 3 mm or less. This close correlation indicates that satisfactory radiographic tunnel position influences outcome after anterior cruciate ligament reconstruction.

Acute dislocations of the distal radioulnar joint

An injury to the DRUJ can occur in association with almost any fracture of the forearm or as an isolated phenomenon. A dislocation of this joint may be simple or complex. Constant awareness must be maintained during treatment of injuries of the wrist, forearm, and elbow if common pitfalls are to be avoided. Failure to diagnose and treat a complex DRUJ dislocation will lead to chronic, persistent subluxations or dislocations, or both, and to symptomatic osteoarthrosis. Failure to recognize a simple dislocation of the DRUJ associated with a fracture of the forearm may result in inappropriate or inadequate immobilization of the dislocated joint after internal fixation of the fracture. As a consequence, the injured TFCC may not heal, leading to recurrent post-operative instability. After either a simple or a complex dislocation of the DRUJ has been recognized, the treatment is relatively straightforward and rewarding. Despite the severity of these injuries, with proper diagnosis and management most patients will have a satisfactory outcome.

Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study

We conducted a prospective, randomized study of open and closed kinetic chain exercises during accelerated rehabilitation after anterior cruciate ligament reconstruction to determine if closed kinetic chain exercises are safe and if they offer any advantages over conventional rehabilitation. The closed kinetic chain group used a length of elastic tubing, the Sport Cord, to perform weightbearing exercises and the open kinetic chain group used conventional physical therapy equipment. Results are reported with a minimum 1-year followup (mean, 19 months). Pre- and postoperative evaluation included the Lysholm knee function scoring scale, Tegner activity rating scale and KT-1000 arthrometer measurements. Overall, stability was restored in over 90% of the knees. Preoperative patellofemoral pain was reduced significantly; 95% of the patients had a full range of motion. The closed kinetic chain group had lower mean KT-1000 arthrometer side-to-side differences, less patellofemoral pain, was generally more satisfied with the end result, and more often thought they returned to normal daily activities and sports sooner than expected. We concluded that closed kinetic chain exercises are safe and effective and offer some important advantages over open kinetic chain exercises. As a result of this study, we now use the closed kinetic chain protocol exclusively after anterior cruciate ligament reconstruction.

In search of the perfect ACL brace

Following my own acute anterior cruciate ligament (ACL) tear and reconstruction, I embarked on a subjective evaluation of ACL functional braces voluntarily supplied by vendors. Both custom and off-the-shelf braces were evaluated during daily activities and running. Scored subjectively on an ascending scale of 1 to 3 were Comfort (including freedom from slippage, abrasions, and pressure phenomena), Convenience (ease of application), Control (perceived resistance to anterior tibial translation), and Cosmesis (appearance, profile). On this rating scale, 1 represents below average, 2 is average, and 3 is above average. The Comfort score was doubled, as this feature determined whether the brace would be worn. The individual scores were then totaled for an overall rating. To avoid bias, I did all trials prior to reviewing the literature. Scores for custom braces were: Townsend, 14; Omni Scientific Elite, 11; Innovation Sports C.Ti.2, 10; 3M Lenox Hill Spectralite, 9; Orthotech Performer, 9; DonJoy Defiance, 9; and Sutter Talon, 9. Scores for OTS braces were: DonJoy Goldpoint, 13; Orthotech Controller, 11; Bledsoe Force III Light, 11; 3M Lenox Hill OTS, 10; Innovation Sports MVP, 8; Bledsoe Force II, 8; Bledsoe Force II Light, 8; Omni Scientific Spectrum, 7; Townsend OTS, 7; and DonJoy Playmaker, 6. This study does not validate the requirement for a functional orthosis following ACL reconstruction, but if one is desired, I prefer the custom Townsend and the OTS DonJoy Goldpoint. Two other higher scoring OTS braces also proved satisfactory (OTS Orthotech Controller and OTS Bledsoe Force III Light). To accommodate the majority of patients, orthopedic surgeons may need to provide a variety of OTS braces.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical significance of leg-length inequality after total hip arthroplasty

Sixty-eight patients were interviewed and examined after total hip arthroplasty (THA) to determine the clinical consequences (patient satisfaction, shoe lift use, gait abnormalities, etc) of leg-length inequality. No patient met clinical or radiographic criteria for revision THA. Minimum follow-up was 2 years, and average follow-up was 6.6 years (range, 2 to 20.5 years). A questionnaire, with specific questions about leg-length inequality, was completed by each patient. Leg-length inequality was determined by orthoroentgenography and compared with clinical measurements of leg length. The average inequality in this series of patients was 9.7 mm. A significant number (32%) of patients were aware of this inequality; the average leg-length inequality in this group was 14.9 mm. More than half of these patients were disturbed by the inequality. The magnitude of leg-length inequality closely correlated with awareness of the inequality, abnormal gait, use of ambulatory assistive devices, the need for a shoe lift, prior leg-length inequality, and revision THA. Clinical measures of leg-length inequality correlated poorly with values determined orthoroentgenographically. The high rate of dissatisfaction among patients with a leg-length inequality and the untoward results associated with this inequality indicate that surgeons performing THA should familiarize themselves with a reliable method for equalizing leg lengths intraoperatively.

Analgesia for the reduction of fractures in children: a comparison of nitrous oxide with intramuscular sedation

A prospective, randomized study was undertaken to compare the effectiveness of nitrous oxide with intramuscular sedation (meperidine and promethazine) in providing analgesia and amnesia during the reduction and treatment of children's fractures in an outpatient clinic setting. Fifteen patients received a 50:50 mixture of nitrous oxide and oxygen, and 15 received intramuscular injection. The two groups were similar in regard to gender distribution, age, and fracture types. Pain response was recorded using the Children's Hospital of Eastern Ontario (Canada) Pain Scale (CHEOPS) at the time of fracture reduction and 30 min postreduction. At the first follow-up visit a questionnaire regarding the patient's memory and subjective experience of the fracture reduction was answered. Data between the two groups were compared using the Mann-Whitney test. The CHEOPS scores, and the memory and subjective experience of the fracture reduction were similar between the two groups. Time in the outpatient department averaged 83 min for the intramuscular group and 30 min for the nitrous oxide group (p < 0.01). All of the nitrous oxide patients stated they would use nitrous oxide again, whereas only eight of 15 intramuscular patients stated they would try intramuscular sedation again. Nitrous oxide is as effective as intramuscular sedation in providing analgesia and amnesia in the treatment of children's fractures while having a more rapid onset and a shorter recovery period with greater patient acceptance.

Does memory constrain utilization of top-down information in spoken word recognition? Evidence from normal aging

Young and elderly adults heard recorded words that had been computer-edited from connected speech so as to be heard in isolation from their linguistic surround. Word identification was tested for words in isolation and when heard with increasing amounts of linguistic context that had either preceded or followed them in their original utterances. Although the elderly subjects were poorer in identifying the words in isolation compared to young adults, both age groups showed similar increases in correct word identification as increasing amounts of prior context were presented. By contrast, context that followed the target words was less effective for the elderly subjects than it was for the young. It is argued that a memory trace of the unclear stimulus must be maintained for effective utilization of following context in a retrospective analysis. The elderly subjects' relative inability to utilize following context implicates an age-related memory deficit operating at the sentence level.

Radionuclide imaging of the knee with chronic anterior cruciate ligament tear

We studied the results of bone scans in 50 consecutive patients with symptomatic, unilateral, chronic anterior cruciate ligament (ACL) tears. All patients had failed conservative therapy and underwent radionuclide imaging of the knee prior to arthroscopic ACL reconstruction. The scintigraphic activity in each of the three knee compartments was quantitatively scaled from 1 (normal scintigraphic activity) to 4 (marked activity). Quantitative activity in each of the three compartments was correlated with plain radiographic, arthroscopic, and clinical findings. All but four of the scans (92%) showed abnormal scintigraphic activity. The quantitative activity was highest overall in the medial compartment (2.9), followed by the lateral (2.4) and patellofemoral compartments (1.9). In the subgroup of patients with normal menisci (10 patients), most of the abnormal activity was in the lateral compartment (2.9), implying that when the medial meniscus remains competent in the presence of a torn ACL, there is increased stress on the lateral compartment. There was little correlation with scintigraphy and roentgenographic changes, except in the presence of moderate or severe radiographic degenerative arthritis. Similarly, there was little correlation between increased scintigraphic activity and chondromalacia. These results provide a baseline for future studies that use scintigraphic imaging in monitoring restoration of bone homeostasis following ACL reconstruction.

Return of normal gait patterns after anterior cruciate ligament reconstruction

Individuals with anterior cruciate ligament deficiency typically do not have quadriceps activity during stance. This aberrant pattern has been termed "quadriceps avoidance" gait. We performed gait analysis during walking on 10 normal controls and 10 subjects 8 to 12 months after they had anterior cruciate ligament reconstruction using autogenous middle third of the patellar tendon. All patients had good subjective and objective results at the time of analysis. Differences in gait between subjects and controls persisted up to 12 months after surgery. Specifically, subjects with anterior cruciate ligament reconstructions demonstrated significant reductions in midstance knee flexion moments (P < 0.01) and tibially directed loading rates (P < 0.05) when compared with controls. However, the subjects had a net external flexion moment throughout most of the stance phase of gait, implying that quadriceps activity was present. After anterior cruciate ligament reconstruction, there is a tendency toward gait normalization, and a quadriceps avoidance mechanism is no longer present.

High tibial osteotomy: fixation with cannulated screws

There have been many modifications of the proximal tibial osteotomy since it was initially described by Jackson in 1958. The trend toward rigid internal fixation and early motion after osteotomy prompted the authors to develop a technique using cannulated screws for stabilization. This method is simple and quick, involves no soft-tissue dissection, and allows early postoperative motion.

Mason type II radial head fractures: operative versus nonoperative treatment

The most appropriate treatment of Mason type II radial head fractures remains controversial. Recommended treatment has included closed reduction and immobilization, resection, or open reduction and internal fixation. The cases of 29 Mason type II radial head fractures treated at Naval Hospital Oakland from 1983 to 1989 were identified. Twenty-six or 90% were available for detailed follow-up. All cases underwent standardized elbow evaluations and results were compared using an elbow score based on a 100-point scale. The parameters evaluated were pain, motion, elbow and grip strength, and function in activities of daily living. In addition, injury and follow-up radiographs were analyzed. Mean follow-up was 18 months. There were 10 cases treated by open reduction and internal fixation and 16 cases treated by closed means. At final follow-up, the operatively treated group had a mean elbow score of 92 and 90% good/excellent results. The nonoperatively treated group had a mean elbow score of 77 and 44% good/excellent results. This difference was statistically significant (p less than 0.01). Radiographic analysis revealed a higher incidence of articular depression, displacement, and joint narrowing in the nonoperatively treated group. We conclude that displaced radial head fractures treated nonoperatively have a higher incidence of pain, functional limitations, loss of strength, and radiographic evidence of arthritis when compared to those treated by open reduction and internal fixation.

Results of conservative treatment for recalcitrant anterior knee pain in active young adults

The purpose of this study was to determine the success rate of a standard rehabilitation protocol in the treatment of recalcitrant anterior knee pain in active young adults. All patients were active military duty personnel. Patients with a diagnosis of recalcitrant anterior knee pain were enrolled in a standard supervised program of physical therapy. Between 1986 and 1989, 139 patients met the criteria for inclusion in the study. The average age was 25.5 years, and the average time in military service was 67 months. There were 123 men and 16 women. The average duration of supervised treatment was 5.3 months. Only 34% (47 patients) were successfully returned to duty. The remainder received medical discharges. Statistically significant factors associated with successful return to full duty included older age (27.4 vs 24.5 years) and longer duration in service (98 vs 51 months). In addition, patients who returned to duty did so after an average of only 3 months of supervised rehabilitation, whereas treatment failures averaged 7.5 months of therapy.

Multidirectional shoulder instability. Clinical results of inferior capsular shift in an active-duty population

We reviewed the results of a capsular shift procedure performed on 10 active-duty patients with an average of 28 months follow-up. Improvement in pain, function, and stability occurred postoperatively in nearly all patients. Loss of total elevation and external rotation were minimal and an average of three spinal segments of internal rotation were lost. Only one patient required further surgery for recurrent instability and all patients except two reported over-all improvement. Dominant shoulders made greater improvements in pain, stability, and functional capacity than nondominant shoulders. Patients with generalized ligamentous laxity had less pain and more posterior instability than those without laxity. A history of an acute traumatic event was predictive of greater improvement in pain and stability. A previous instability repair was indicative of the most postoperative instability and least functional improvement.

Nonoperative management of herniated nucleus pulposus: patient selection by the extension sign. Long-term follow-up

We have previously reported that the ability of patients with herniated nucleus pulposus (HNP) and radiculopathy to achieve full passive lumbar extension (negative extension sign) is a useful predictor of favorable response to conservative management. Of 154 patients with back pain and radiculopathy seen between 1979 and 1985, 73 were selected for conservative management based on this criterion. We also reviewed results of electromyography (EMG), computed tomography (CT), myelography, straight leg raise, crossed straight leg raise, deep tendon reflex, and dermatomal-sensory and motor deficits. Ninety-four percent of the subjects achieved full extension within 5 days of hospital admission. Although some patients who had full extension on admission subsequently underwent chemonucleolysis or surgery, none of those who could not extend initially and who later gained full lumbar extension required surgery. Of the 33 patients who were available for long-term follow-up, 94% were satisfied with the results, 82% were able to resume working, 73% required no analgesics, and 9% later required chemonucleolysis or surgery. Positive findings on admission EMG (5 of 7 patients), myelography (5 of 8 patients), or CT (9 of 11) did not preclude good results with conservative management. Female patients without complaint at follow-up (53%) outnumbered their male counterparts (25%). Patients (19 of 33) whose extension sign was initially positive on admission and became negative within 5 days of hospitalization (average, 1.6 days) had better outcomes with 95% satisfied, 90% without job changes, 74% not requiring analgesia, and none requiring surgery. At long-term follow-up, the extension sign effectively predicted a favorable response to nonoperative therapy of HNP in 91% of cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Complex dislocations of the distal radioulnar joint. Recognition and management

Contrary to most reported series, it has been the authors' experience that dislocations of the distal radioulnar joint (DRUJ) associated with fractures of the forearm are frequently irreducible. This report reviews the authors' experience with these injuries, focusing on the recognition and management of what the authors call "complex" DRUJ dislocations: dislocations characterized by obvious irreducibility, recurrent subluxation, or "mushy" reduction caused by soft tissue or bone interposition. From 1984 until 1989, at the authors' institution, 11 patients were treated for fractures of the radius associated with dislocations of the DRUJ. Eight of these patients had a classic Galeazzi fracture dislocation. Two patients had severe open radius and ulnar fractures. One had an unstable comminuted intraarticular fracture of the distal radius. Of these 11 patients, four had "complex" dislocations of the DRUJ. In two cases, the extensor carpi ulnaris was displaced volar to the distal ulna, necessitating open reduction. A third case involved delayed recognition of multiple wrist and forearm joint dislocations associated with a severe open fracture of both bones of the forearm and required late exploration, reduction, and temporary internal fixation. A fourth case involved recurrent dorsal subluxation of the distal ulna after open reduction and internal fixation of a comminuted intraarticular distal radius fracture. It is clear that complex dislocations of the DRUJ occur more frequently than previously noted. Careful attention to these injuries during initial reduction attempts will reveal "mushy" or unobtainable reductions, an important indication for exploration for entrapped tendon, bone, or soft tissue.

Arthroscopic treatment of symptomatic synovial plica of the knee. Long-term followup

We studied all patients undergoing arthroscopic resection of symptomatic plica without other intraarticular abnormality at our institution from October 1981 to March 1987. To be considered abnormal, plicae had to be thickened and/or fibrotic when viewed arthroscopically. Seventy-six of nearly 2000 patients (4%) who underwent diagnostic arthroscopies met our inclusion criteria. Clinical response after arthroscopic resection was evaluated in 51 patients at an average of 47 months (range, 15 to 77). Excellent or good results were obtained in 57 (75%) of the patients. Eleven patients (14%) had an impingement lesion defined as a localized femoral condylar ridge or groove of the articular surface that impinged upon the plica with increasing flexion. All of these patients had an excellent or good result. Other factors associated with a favorable outcome included a specific preoperative diagnosis localizing symptoms to the medial compartment, onset of pain after a period of increased athletic activity or after a twisting injury, and younger age. Poor prognostic factors included associated chondromalacia and an unclear preoperative diagnosis.

Patellar fracture and avulsion of the patellar ligament complicating arthroscopic anterior cruciate ligament reconstruction

Arthroscopic reconstruction of the anterior cruciate ligament-deficient knee using the middle third of the patellar tendon is an effective treatment for acute or chronic anterior cruciate ligament insufficiency. The strength of this bone-ligament-bone graft is superior to virtually all other autogenous tissue utilized. We report the complication of avulsion of one half of the remaining patellar tendon from the tibia associated with patellar fracture in the early postoperative period.

The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults

The results of nonoperative treatment of 72 patients with complete anterior cruciate ligament (ACL) tears, documented by examination under anesthesia and arthroscopy, were evaluated. All patients had an acute injury with hemarthrosis in a previously normal knee. Patients having meniscal repair were excluded as were those with collateral or posterior cruciate ligament tears or associated fractures. Treatment in all cases consisted of a standard protocol of early rehabilitation and bracing. A detailed rating of symptoms and function was performed at an average of 38 months postinjury (range, eight to 84 months). Overall results were 11% excellent, 20% good, 15% fair, and 54% poor. Thirty-five percent had ACL reconstruction during the follow-up period. Results indicate that young adults who return to a vocation requiring strenuous physical activity frequently can expect unsatisfactory results after nonoperative treatment of an acute complete tear of the ACL.

Partial versus complete acute anterior cruciate ligament tears. The results of nonoperative treatment

A study was undertaken to determine whether a significantly different clinical outcome could be expected following nonoperative treatment of acute partial anterior cruciate ligament (ACL) tears from that of complete tears. A detailed follow-up of 107 patients with arthroscopically confirmed tears was obtained; 72 were complete tears and 35 partial. The overall results in those with partial tears were 23% excellent, 29% good, 17% fair, and 31% poor; with complete tears the results were 11% excellent, 20% good, 15% fair, and 54% poor. The patients with partial tears had a lower incidence of associated meniscal tears, needed fewer reconstructions and more of them returned to sport than those with complete tears.

Lunate silicone replacement arthroplasty in Kienböck's disease: a long-term follow-up

We report a long-term follow-up (average, 5 years) of 10 patients who had lunate silicone replacement arthroplasty for treatment of Kienböck's disease. Clinical results were assessed on relief of pain, return to normal occupation, and range of motion. At 18- to 20-months follow-up, eight patients had satisfactory results, whereas at final follow-up only five of the patients had satisfactory results. Three of five patients with radiographs averaging 57 months after operation had evidence of particulate synovitis. Contrary to our previous publications on silicone replacement arthroplasty, it was concluded that the success rate for silicone replacement arthroplasty and the incidence of particulate synovitis do not warrant the continued use of silicone replacement arthroplasty as a primary treatment modality for Kienböck's disease.

Arthroscopy update #6. Arthroscopy in the osteoarthritic knee. Long-term follow-up

A retrospective review was performed of 109 patients who underwent arthroscopic debridement of the knee for degenerative osteoarthritis. The results were evaluated using a modification of the Hospital for Special Surgery (HSS) scoring system as well as a subjective scale that measured the patients' degree of satisfaction with the procedure. Follow-up was obtained in 111 knees for an overall follow-up of 92% of knees. The mean age of the patients was 58.1 years, and the mean follow-up was 50.6 months. The overall results were 50 good, 20 fair, and 41 poor. Arthroscopic debridement offered measurable relief for 63% of the patients for a significant period of time. Although the results are equivocal by orthopaedic standards, 74% of the patients felt the procedure had been beneficial.

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.