Interarticular bone tunnel healing.

PURPOSE: To evaluate the healing behavior of an interarticular bone tunnel exposed continuously to a synovial environment. TYPE OF STUDY: Experimental in vivo animal model. METHODS: Twenty-six adult rabbits had 3.2-mm diameter tunnels drilled in the femur and tibia of both hind-limb stifle joints parallel to but without violation of the native anterior cruciate ligament (ACL). The animals were euthanized at 1, 2, 4, and 12 weeks postoperatively. Decalcified sections were made of the bone tunnels and new bone formation was computer quantified using histomorphometric methods at each time interval. RESULTS: In this model, bone tunnel healing velocity was most rapid between 1 and 2 weeks after surgery. Both femoral and tibial interosseous tunnels showed substantial bone ingrowth (71% of bone tunnel volume) by 2 weeks postoperatively. The peripheral tunnel segment, that third of the tunnel furthest from the joint surface, healed rapidly and was 99% occluded with bone (99% confidence interval, 93.7% to 100%) at 2 weeks. Tunnel ingrowth was delayed and incomplete in the articular third of the tunnel, especially the femoral side. At 12 weeks, by volume, only 69.1% (99% confidence interval, 52.3% to 85.7%) of the interarticular third of the femoral tunnel was ingrown with new bone. Peripheral third bone tunnel healing was significantly greater than articular third tunnel healing at all time intervals; P <. 005 for the femoral and P <. 05 for the tibial tunnel. CONCLUSIONS: Interarticular bone tunnels heal from the outside in. At 12 weeks, bone healing was slower and incomplete in the articular segment of the tunnel, closest to the joint surface. The same biologic factors that impede intersubstance ACL healing may interfere with bone tunnel healing and be another cause of bone tunnel enlargement after ACL reconstruction.

Template versus freehand bone-patellar tendon-bone harvest for anterior cruciate ligament reconstruction: its effect on patellofemoral morbidity.

To test the hypothesis that a template system for harvesting bone-patellar tendon-bone (BTB) would cause fewer postoperative patellofemoral problems than freehand graft harvests, two groups of 20 patients who had arthroscopically assisted anterior cruciate ligament (ACL) reconstructions were compared at 1 and 3 years. Three years after surgery, no significant differences were found in the quality of the ligament reconstruction. One intraoperative patellar fracture occurred in the freehand group (group 1). All other complications were similar between groups. Squatting profiles were slightly better in the template group (group 2). Averaged and outlier scores from three published patellofemoral scoring systems showed no significant differences between the two groups. It was concluded that current methods for measuring patellofemoral function detected little morbidity and no significant outcome differences between ACL reconstructions done with BTB grafts harvested by freehand versus templated techniques.

Elbow dislocation with arterial injury.

Elbow dislocations are most often the result of a hyperextension mechanism with the forearm levered and displaced posterior to the humerus. Recurrent instability and arterial disruption are uncommon sequelae of this injury. Any asymmetry in distal pulses after joint reduction demands a study of arterial anatomy (arteriogram or duplex scan) to rule out avulsion or intimal damage.

Patient outcomes after minimally destabilizing lumbar stenosis decompression: the "Port-Hole" technique.

STUDY DESIGN: A prospective evaluation of the outcome of a decompressive procedure for lumbar spinal stenosis designed to preserve spinal stability. OBJECTIVES: To determine whether decompression could be achieved without subsequent fusion for spinal stenosis with and without degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: The traditional surgical decompression of spinal stenosis involves removal of the posterior elements. Success occurs in 64% of cases, on the average, with results deteriorating over time. Concomitant spinal fusion is associated with higher costs and complication rates. METHODS: This prospective study included 54 consecutive patients treated surgically by one surgeon. Patients were contacted 21/2 and 4 years, on the average, after surgery. Patients with spondylolisthesis were evaluated for worsening of the listhesis after surgery. RESULTS: At a mean of 4 years after surgery, all patients were satisfied with their treatment. Concerning their symptoms, 80% reported relief of back pain; 96% had improvement of leg pain; 93% experienced relief of leg numbness; and 97% had relief of lower extremity weakness. Before surgery, only 1 patient could walk for longer than 15 minutes. After surgery, 98% (47/48) could walk for more than 15 minutes. Overall clinical results were graded as good to excellent (88%), fair (8%), or poor (4%). Clinical outcomes were comparable between those with and without degenerative spondylolisthesis (P = 0.08). Patients with degenerative spondylolisthesis showed no change in the amount of slip in 13/15 patients (87%). CONCLUSIONS: Degenerative spinal stenosis, even with nonlytic spondylolisthesis, can be decompressed effectively without violating the integrity of the posterior elements.

The lateral elbow ligaments. A correlative radiographic study.

Knowledge of the lateral elbow ligaments' normal anatomic relationships to osseous structures, as seen on standard radiographs, can facilitate the interpretation of arthrograms and an understanding of fracture mechanisms. We dissected fresh cadaveric elbows to isolate the entire lateral ulnar collateral and annular ligaments as well as their sites of osseous origin and insertion. We obtained radiographs of each ligament after painting them with a special radiopaque tantalum powder cyanoacrylic preparation. The resulting study allowed radiographic depiction of these important soft tissue structures in relation to the attendant osseous anatomy.

Posterior cruciate ligament recession.

Three cases of posterior cruciate ligament (PCL) laxity without posterolateral rotatory instability had magnetic resonance imaging scans that documented the structural continuity of the PCL. Tibial PCL recession was effective in eliminating symptomatic laxity in 1 case and lacked efficacy in the other 2 cases.

Adolescent tibia vara, nonossifying fibroma, and bipartite patella in a nationally ranked adolescent karate competitor.

I describe a case of adolescent tibia vara, a contralateral nonossifying fibroma of the tibia, and bipartite patella, which occurred in an adolescent karate competitor of normal stature. The association of this unusual triad supports the hypothesis that each process has a shared traumatic etiology.

Extensile exposure of comminuted patella fractures using a tibial tubercle osteotomy: results of a new technique.

OBJECTIVE: To evaluate the clinical results of comminuted patella fracture fixation after an extensile surgical approach by using a tibial tuberosity osteotomy. DESIGN: Prospective, clinical. PATIENTS: Six knees with displaced comminuted patella fractures had stable internal fixation after an osteotomy of the tibial tubercle. All had immediate postoperative continuous knee motion and were followed for an average of thirty-one months (minimum of eighteen months). OUTCOME MEASURES: Time to clinical and radiographic union, Hospital for Special Surgery (HSS) Knee Scores and comparisons with literature cohort studies. RESULTS: Clinical union of the osteotomy occurred at an average of eight weeks (range 6 to 12 weeks) and of the patella fractures at an average of eleven weeks (range 8 to 21 weeks). There was no radiographic evidence of osteotomy displacement, fracture implant loosening, migration, or failure. All patients had clinical residua, which included loss of motion, thigh muscle atrophy, and barometric complaints. HSS Knee Scores averaged 75 points with four good, one fair, and one poor result. These results were comparable to those of previously published reports of ablative surgery for this type of fracture. CONCLUSION: Comminuted patella fractures are severe injuries that usually result in some lingering morbidity. Internal fixation preserves bone stock, which facilitates future reconstructive procedures. The described tibial tuberosity osteotomy, patella eversion technique of fracture exposure improved visualization and reduction of the articular surface. The osteotomy healed in all cases and did not adversely affect the clinical results.

A clinical test for superior glenoid labral or 'SLAP' lesions.

OBJECTIVE: To describe a clinical test associated with unstable lesions of the superior glenoid labrum-long head biceps tendon origin, or SLAP (superior labrum anterior to posterior). DESIGN: Description of a newly discovered clinical sign that correlated with SLAP pathology. Retrospective review of 66 consecutive arthroscopically confirmed SLAP lesions to determine the sensitivity of the SLAPprehension test. SETTING: Orthopedic sports medicine clinics with an emphasis on shoulder problems. PATIENTS: Patients with shoulder pain and arthroscopically verified lesions of the superior glenoid labrum and conjoined long head biceps tendon. INTERVENTION: Shoulder arthroscopy and in some cases arthroscopic SLAP lesion repair. OUTCOME MEASURES: Nonapplicable. RESULTS: The SLAPprehension test involves cross chest adduction (horizontal flexion) of the affected shoulder with the elbow extended and forearm pronated. A positive maneuver produces either apprehension, pain referable to the bicipital groove, and an audible or palpable click. The test is repeated with the forearm supinated, which must cause diminution of the pain. Mechanically, elbow extension and forearm pronation places traction on the long head biceps tendon. When anterior scapular protraction is limited by the clavicle, further adduction entraps the unstable biceps tendon and superior glenoid labrum between the glenoid fossa and humeral head. Forearm supination decreases traction on the long head biceps tendon and allows for reduction of the unstable labrum complex with lessening of the pain. A retrospective chart review of 66 consecutive arthroscopically verified shoulders with SLAP lesions revealed the SLAPprehension test to be 87.5% sensitive for unstable SLAP lesions. CONCLUSIONS: The SLAPprehension test is helpful in the clinical evaluation of patients with unstable superior glenoid labrum lesions whose symptoms are often confused and overlap with those of shoulder impingement or acromioclavicular arthrosis.

Open book (AP compression) pelvis fracture.

A simple pelvic fracture classification is presented based on the metaphor of a pelvis as a book. Resuscitative fluid and blood requirements can be estimated by knowledge of the pelvic fracture pattern. Open book (AP compression) pelvis fractures generally have the largest amounts of blood loss.

Knee joint arthroscopy in the morbidly obese.

Ten morbidly obese individuals were retrospectively reviewed to determine the technical problems and incidence of surgical complications associated with knee joint arthroscopy in this subpopulation of patients. In comparison to a cohort of patients of normal weight that were matched for age, sex, and surgical procedure, the morbidly obese patients had longer operative times (P < .02) and time to work resumption despite having less physically demanding jobs. Those with morbid obesity required a greater number of arthroscopy portals to effect a thorough arthroscopic examination (P < .02). Many technical problems involved the fact that these patients' size could not be accommodated by standard equipment. There were no wound or neurovascular complications and one presumed thromboembolic event.

An intra-articular fracture-dislocation of the acromioclavicular joint.

A hybrid acromioclavicular joint fracture-dislocation in which an intra-articular fracture of the distal clavicle coexisted with a coracoclavicular ligament injury is described. The proposed mechanism of injury is a fall on the point of the shoulder that simultaneously drives the scapula both anteriorly and inferiorly. Forced anterior scapular protraction caused a displaced horizontal plane fracture of the inferior half of the distal clavicle, which was separated from the remainder of the clavicle. The inferiorly acromioclavicular ligament was still attached to this distal clavicle fragment. The inferiorly directed force ruptured the coracoclavicular and superior acromioclavicular ligaments.

Charcot arthropathy after acetabular fracture.

Three middle-aged patients with diabetes sustained fractures of the acetabulum which were treated by open reduction and internal fixation. In each, rapid dissolution of the femoral head occurred with minimal discomfort, typical of a Charcot arthropathy. The patients had no other evidence of neuropathic arthropathy. Charcot changes may occur after high-energy trauma in patients with diabetes.

The SLAP lesion: a cause of failure after distal clavicle resection.

Persistent pain after distal claviculectomy (the Mumford procedure) has been attributed to both inadequate and excessive clavicle resection or incomplete supraspinatus outlet decompression with continued impingement. A retrospective review of twenty glenohumeral arthroscopies done in shoulders with a previous Mumford procedure disclosed 15 cases, (75%) of superior glenoid labrum, long head biceps tendon (SLAP) lesions. Most of the distal calvicle resections 13 out of 15 (86%) had been done for "acromioclavicular arthritis." These patients were young, with an average age of 37 years (range 20 to 50) and most, 14 out of 15, had pain attributable to a specific traumatic event. Most had deep pain referable to the bicipital groove with cross chest adduction of the shoulder with the elbow extended and forearm pronated (thumb down). The discomfort improved with the forearm supinated (thumb up). It is concluded the SLAP lesion to be part of the differential diagnosis of acromioclavicular joint disease. In younger patients with a traumatic history, glenohumeral arthroscopy should be used to rule out SLAP pathology and possibly prevent an unnecessary distal clavicle resection.

Unilateral thoracic facet dislocation.

A unilateral facet dislocation is an injury classically localized to the cervical spine. A series of 3 unilateral thoracic facet dislocations are reported in 2 adults and 1 child. Each had severe concomitant injuries to the thorax, which caused respiratory compromise. On lateral radiographs, all had anterior vertebral body translation of less than 20% of the vertebral body width with minor degrees of kyphosis. Axial computed tomographic images showed a unilateral empty facet sign. All patients were neurologically intact and none had any mechanical pain at last followup. The mechanism of injury is flexion distraction with rotational force that disrupts the rib cage.

Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring through parallel cannulated compression screws.

OBJECTIVE: To evaluate the clinical results of transverse patella fracture fixation with a tensioned anterior figure-eight wire placed through parallel cannulated screws. DESIGN: Prospective, clinical. PATIENTS: Ten patients with displaced transverse patella fractures were managed with a standardized rehabilitation protocol that employed early continuous passive knee motion. OUTCOME MEASURES: Time to clinical and radiographic union, Hospital for Special Surgery Knee Scores, and comparisons with literature cohort studies. RESULTS: Clinical union occurred at an of average eight weeks and radiographic union at a mean of thirteen weeks postoperatively. Early continuous passive motion over a restricted are did not compromise the quality of fracture reduction, even though the majority of patients were elderly and had osteopenic bone. Subjective and functional results using Hospital for Special Surgery Knee Scores were comparable to previously published reports, with 70 percent achieving an excellent or good outcome. CONCLUSIONS: The described fixation technique for transverse patella fractures had clinical results equivalent to reports of patella fractures fixed with modified tension band wiring. Advantages included a low-profile construct that caused lesser degrees of implant irritation to local soft tissue structures, was compatible with the use of early restricted motion, and afforded a method to salvage three cases in which traditional tension band wiring failed to maintain an anatomic reduction in oteoporotic bone.

Radiography of the medial elbow ligaments.

The anterior, posterior, and transverse bundles of the medial collateral ligaments of fresh cadaveric elbows were painted with a special radiopaque tantalum cyanoacrylic preparation. The extent of each ligament and their origins and insertions were examined with radiography. This study provided radiographic correlation for these important soft tissue structures and an anatomic understanding of elbow fractures with ligament avulsion.

Arthroscopic advancement of a tibial nail.

Rapid restoration of maximal extremity function has stimulated the aggressive treatment of tibia fractures with intramedullary nails. Rod migration is a well-described complication of flexible or unlocked intramedullary rods. Interarticular extrusion of an unlocked tibial rod occurred in a patient after a second accident. Arthroscopy was used to evaluate the chondral injury, as well as to advance the rod.

Pelvic trauma imaging: a blinded comparison of computed tomography and roentgenograms.

To determine the sensitivity for detecting pelvic pathology and instability, roentgenograms and computed tomographic (CT) scans from 59 patients with pelvic injuries that had been admitted to a Level I trauma center were randomly reviewed by a orthopedic surgeon blinded to the study. Normal control roentgenograms and CT scans were included to decrease observer bias. The anteroposterior (AP) roentgenogram detected 66% of all pelvic injuries, 78% of those involving the anterior ring, and 53% of those involving the posterior pelvic ring. The trauma CT scan, 10-mm axial images of the abdomen and pelvis, detected 86% of all pelvic injuries, and 78% of anterior ring and 93% of posterior ring injuries. The sensitivity for detecting pelvic instability from one plain film AP pelvis roentgenogram taken in a trauma room setting was 74%. Inlet and outlet views were 75% sensitive. Trauma CT scans were 93% sensitive and high-definition pelvic CT scans (5-mm pelvic cuts) yielded 100% sensitivity. The mechanism of injury could be ascertained with 73% sensitivity by plain films and with 79% sensitivity by inlet and outlet views; trauma CT scans were 96% and high-definition pelvic CT scans were 100% sensitive. When combined, the AP pelvis roentgenograms and trauma CT scans identified 96% of the injured structures and were 100% sensitive in determining injury force patterns and instability. The data suggested that a good quality AP pelvis roentgenogram in conjunction with a complete trauma CT scan of the abdomen/pelvis should identify both the injury mechanism and pelvic instability with a high degree of sensitivity.