Functional bracing for rupture of the Achilles tendon. Clinical results and analysis of ground-reaction forces and temporal data.

Fifteen patients who had sustained a rupture of the Achilles tendon were managed non-operatively with use of a functional bracing protocol, and clinical and functional performance measures were assessed after a mean duration of follow-up of thirty-one months (range, twenty-four to forty-five months). An age and gender-matched group of fifteen subjects was assessed to provide normative data for the comparison of side-to-side differences. Numerical scores were generated on the basis of subjective responses to a questionnaire, clinical measurements of the range of motion of the ankle and the circumference of the calf, and the results of the Thompson squeeze test and a single-limb heel-rise test. A 100-point scoring system was used to categorize the outcome as excellent, good, fair, or poor. In addition, ground-reaction forces and temporal data were assessed during functional dynamic activities that included walking, a single-limb power hop, and a thirty-second single-limb heel-rise endurance test. The result was graded as excellent for three patients, good for nine, fair for two, and poor for one. An increase in passive dorsiflexion of the treated ankle was the only clinical measure that was significantly different between the groups (p = 0.02). This increase in dorsiflexion was positively correlated with vertical force output between the mid-stance and terminal-stance phases of gait (r = 0.40, p = 0.05). With the numbers available, we could detect no significant differences between the groups with regard to the kinetic or temporal variables that were measured during functional dynamic activities. Patients who generated less peak vertical force and vertical height during the single-limb power-hop test tended to have poorer clinical scores. We believe that non-operative functional bracing may prove to be a viable alternative to operative intervention or use of a plaster cast for the treatment of acute ruptures of the Achilles tendon. The goals of treatment are to prevent the musculoskeletal changes that are associated with immobilization, to reduce the time needed for rehabilitation, and to facilitate an early return to work and to preinjury activities.

The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures.

A total of 18 competitive and recreational athletes were enrolled in a randomized, prospective study looking at the effect of pneumatic leg braces on the time to return to full activity after a tibial stress fracture. All patients had positive bone scans and 15 had positive radiographic findings by Week 12. There were two treatment groups. The traditional treatment group was treated with rest and, after 3 pain-free days, a gradual return to activity. The pneumatic leg brace (Aircast) group had the brace applied to the affected leg and then followed the same return to activity guidelines. The guidelines consisted of a detailed functional progression that allowed pain-free return to play. The brace group was able to resume light activity in 7 days (median) and the traditional group began light activity in 21 days (median). The brace group returned to full, unrestricted activity in 21 +/- 2 days, and the traditional group required 77 +/- 7 days to resume full activity. The Aircast pneumatic brace is effective in allowing athletes with tibial stress fractures to return to full, unrestricted, pain-free activity significantly sooner than traditional treatment.

Arthroscopic medial meniscal repair in the athlete.

Meniscal tears are common sports injuries. This article details the clinical evaluation of the athlete presenting with knee pain. Conservative (nonoperative) treatment and arthroscopic procedures are discussed.

The management of meniscal tears in the ACL-deficient knee.

Concomitant ACL and meniscal tears pose a higher risk for premature osteoarthritis than either condition alone, especially in the active athlete. Given that the ACL-deficient knee is also at risk of initiating tears and propagating smaller tears, ACL reconstruction is advisable. The meniscal repair in the ACL-unstable knee is at a higher risk for retear. Therefore, ACL reconstruction should be considered seriously for the ACL-deficient patient with a reparable meniscal tear, as well as for the irreparable meniscal tear, as long as the patient is an otherwise appropriate reconstruction candidate. The meniscal tear with a vertical longitudinal pattern that is less than 5 mm from the meniscosynovial junction and longer than 10 mm should be repaired. Tears with rim widths greater than 5 mm may be repaired if there is evidence for vascularity. Those tears that have rim widths greater than 5 mm without evidence for significant vascularity may be repaired, but healing enhancement techniques are recommended, including rasping of synovial fringes and insertion of fibrin clot, and both the patient and the surgeon need to be aware of the significantly lower success rates. If repairs of double flap, double longitudinal, or radial tears are performed, then use of the fascia sheath coverage with fibrin clot, as proposed by Henning et al, can be considered. Partial meniscectomy is acceptable for the complex meniscal tear.

Long-term results of open meniscal repair.

The purpose of this study was to document the long-term clinical and radiographic results of open meniscal repair. Thirty consecutive patients, involving 33 open repairs, were evaluated by history, physical examination, KT-1000 arthrometer testing, Lysholm II score, Tegner activity score, and weightbearing radiographs. The mean followup was 10.9 years (range, 10.1 to 13). No patients were lost to followup. Seven meniscal retears (21%) were documented (six demonstrated by repeat arthroscopy and one suspected on clinical evaluation). Three of 21 (14%) acute repairs (performed within 6 weeks of injury) retore as compared with 4 of 12 (33%) chronic repairs (P = 0.38). None of the 12 menisci in stable knees (< 3 mm side-to-side difference in anterior laxity on manual maximum load testing) sustained retears, compared with 7 of 21 (33%) menisci in nearly stable or unstable knees (P = 0.03). Standing radiographs revealed no degenerative changes in 22 of 26 (85%) compartments with successful repairs as compared with 3 of 7 (43%) compartments with retorn menisci (P = 0.04). We concluded that the long-term survival rate of repaired menisci was 79%, that increased retear rates were encountered in unstable knees, and that radiographs provided evidence for the biomechanical function of successful meniscal repairs.

Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft.

A retrospective analysis was performed to explain the decreasing incidence of postoperative arthrofibrosis of the knee in 191 consecutive patients who had anterior cruciate ligament reconstruction using the central third patellar tendon from 1987 through 1991. Follow-up data were available on 188 patients (98%). Age, sex, time interval from injury, preoperative motion, and concomitant meniscal repair or partial meniscectomy were evaluated for their significance as risk factors. Twenty-two of 188 patients (12%) developed arthrofibrosis; the incidence was lower when the acute anterior cruciate ligament reconstruction was delayed at least 3 weeks from the injury, and when preoperative extension was 10 degrees or better. Age, sex, preoperative flexion, and need for concomitant meniscal surgery were not risk factors. The postoperative motion protocol evolved during the study period. Group 1 patients were braced in 45 degrees of flexion for 1 week before passive extension was allowed. In Group 2, motion was started after 48 hours. Group 3 patients were braced in full extension, with motion starting with 24 hours. With these changes, the incidence dropped from 23% to 3%. Decreases in the incidence of arthrofibrosis with modifications in operative technique and postoperative analgesia were not statistically significant.

[Meniscus resection versus reattachment of the meniscus]. / Meniskusentfernung versus Meniskusrefixation.

Stable partial-thickness tears, longitudinal tears of less than 5 mm length and short (5 mm or less) radial tears can sometimes be left alone. Tears known to be definitely repairable are traumatic longitudinal tears within the vascular zone of the meniscus with minimal damage to the meniscus body fragment. When an attempt is to be made to repair tears in the avascular zone, it is necessary to utilize healing-enhancement techniques such as synovial fringe rasping and fibrin clot insertion. The survival rate for repaired menisci at a minimum follow-up time of 10 years was 79% in the author's cases. Intermediate (5 year) results after partial meniscectomy show a diminished incidence of post-surgical degenerative changes when compared to total meniscectomy.

The surgical treatment of arthrofibrosis of the knee.

Sixty-one lysis of adhesion procedures were performed for arthrofibrosis of the knee between 1981 and 1990. In 43 cases (37 patients) the etiology was prior knee ligament surgery. Ten cases had sustained fractures about the knee and eight had miscellaneous etiologies. Six patients required a second lysis of adhesion procedure. A retrospective analysis of the 43 ligament patients was undertaken to evaluate the results of surgical treatment. All 43 cases were available for followup at an average of 3.6 years. Surgical indications included flexion or extension deficits of > or = 10 degrees or when motion failed to improve despite 2 months of intense therapy. Follow-up assessment included clinical and radiographic evaluation. Flexion improved from 83% to 97% of the contralateral side. Extension deficits improved from 14 degrees to 3 degrees. Only 23 of 37 patients (62%) achieved satisfactory functional results. Radiographic evidence of degenerative changes, soft tissue calcification, and patella infera was found in 89%, 51%, and 9% of the patients, respectively. Patients requiring surgical treatment for arthrofibrosis after knee ligament surgery achieved excellent motion gains, but functional outcome scores were compromised and radiographic findings were concerning. Patients with the localized anterior intraarticular variant or those undergoing lysis of adhesion surgery sooner than 6 months had outcomes comparable with controls.

Long-term followup of the modified Bristow procedure.

A total of 86 modified Bristow procedures were performed for anterior shoulder instability between 1975 and 1987. Followup on 79 shoulders (92%) was obtained at an average postoperative time of 8.6 years. The redislocation rate was 4%. Average motion loss was 5 degrees of internal rotation and 9 degrees of external rotation. Fifteen percent of the patients examined expressed mild apprehension with the shoulder abducted and externally rotated. Radiographic bone union of the coracoid transplant was noted in 82% of patients. Additional surgical procedures were required in 14% of patients. Seventy-three percent of the reoperations were for screw removal because of persistent shoulder pain. The average subjective shoulder function was rated at 86% of preinjury level. All throwing athletes were able to return to throwing, although 54% of the patients with dominant shoulder involvement noted a decrease in throwing velocity. Ninety-seven percent of the patients rated their results as good or excellent.

Current concepts in meniscal repair.

As the importance of meniscal preservation has become recognized, meniscal repair has become a more commonly practiced procedure. We briefly review the current, commonly accepted indications, techniques, and our rehabilitation protocol for meniscal repair. Both open and arthroscopic repairs are reviewed, including the arthroscopic techniques classified as inside-out, outside-in, and all inside. We conclude with a review of the results of meniscal repair and some thoughts on future directions.

Localized pigmented villonodular synovitis presenting as a loose body in the knee.

Localized pigmented villonodular synovitis is a rare condition of the knee that can present with symptoms suggesting internal derangement. We report a case of a patient who presented with signs and symptoms of a loose body in the knee. The lesion was treated with resection using arthroscopic cautery.

The allman modification of the bristow procedure for recurrent anterior glenohumeral instability.

The Bristow procedure has undergone several modifications since Latarjet's original description in 1954. Throughout all the variations, the main principle remains in that the transferred bone block and muscle unit act as a mechanical buttress and sling to reinforce the weak anterior glenohumeral capsule. Several authors have reported satisfactory follow-up results with low rates of dislocation. However, multiple reports exist of complications involving hardware migration and damage to neurovascular structures. We review our previously reported follow-up on 79 shoulders after an Allman modification of the Bristow procedure at an average postoperative time of 8.6 years. The redislocation rate was 4% with average loss of external rotation of 9 degrees and internal rotation 5 degrees . Fourteen percent of shoulders required reoperation, the majority for screw removal. The likelihood of a quick return to full participation in athletics is good, except for the throwing athlete. The modified Bristow procedure provides excellent long-term stability with minimal loss of external rotation. Intraoperative radiographs are recommended to assure proper bone block placement. Patient satisfaction remains high regarding functional outcome.

Open meniscus repair. Indications, technique, and results.

As noted through the work of Fairbank, total meniscectomy is not a benign operation. Cox et al found that meniscectomies in canine knees lead to gross and microscopic degenerative changes. They also noted that partial meniscectomies lead to less severe degenerative changes. They believed that there was a direct relationship between the degree of degenerative change and the amount of meniscus removed. McGinty et al reported early return to function with decreased morbidity and decreased complication rates after partial meniscectomy; this was compared to both open and arthroscopic techniques for total meniscectomy. Jackson and Dandy have documented improved results of partial meniscectomy when compared with total meniscectomy in an intermediate range (average 5 to 10 years) follow-up study. Earlier studies by the senior author, Hamberg et al, and Cassidy and Shaffer have documented that meniscal repairs can heal. The more recent follow-up study of DeHaven et al has documented that repaired menisci not only heal satisfactorily but that durability and biomechanical function can also be maintained. Of course, long-term review of these same patients will be necessary to prove that successful repair will prevent the degenerative changes noted in knees following meniscectomy.

Decision-making factors in the treatment of meniscus lesions.

In recent years, there has been a distinct trend toward a selective approach to the treatment of meniscus lesions. Partial meniscectomy, meniscus repair, and leaving certain tears alone have become alternatives to routine total meniscectomy. Once a meniscus tear is definitively diagnosed, the physician's first decision involves whether to treat the tear surgically or leave it alone. If surgical treatment is judged to be appropriate, the next decision concerns whether it should be repaired or partially excised. Total meniscectomy is reserved for tears for which any other option is unsuitable. The pertinent factors that should be considered in this decision-making process are: (1) the clinical evaluation, (2) associated lesions, and (3) the exact type, location, and extent of meniscus tear.

Open meniscus repair. Technique and two to nine year results.

An average 4.6 year follow-up study has been done on 80 of 104 open meniscus repairs of unstable peripheral tears. Two of nine retears were treated in the acute stage and seven were treated in the chronic stage. Eight retears were medial, one was lateral (repair ratio, 1.5:1 medial to lateral), three occurred through the repair site, and six occurred in different areas. Retears occurred in 1 of 26 isolated repairs, 2 of 38 repairs done with an ACL stabilization procedure, and 6 of 16 repairs done in ACL deficient knees that were not stabilized. Standing radiographs revealed normal compartments in 40 of 41 repairs.

Reflex sympathetic imbalance. Response to epidural blockade.

Eleven patients (two male, nine female) were treated with epidural sympathetic blockade for reflex sympathetic imbalance, an incomplete manifestation of reflex sympathetic dystrophy. Each had developed severe pain, sensitivity, and disability disproportionate to associated trauma. One patient injured an ankle, and the remaining 10 patients one or both knees (12 knees). Seven patients had undergone previous surgery. All but one had a favorable response to initial blockade. This individual eventually failed treatment despite surgical sympathectomy. Seven have required readministration of a block for clinical relapse. Mean followup was 22 months (range, 10 to 41 months). Five underwent extensive psychological testing. All have required adjunctive forms of therapy including physical therapy, transcutaneous electrical nerve stimulation (TENS), antiinflammatory or other nonnarcotic agents. Recovery is typically prolonged, particularly if the diagnosis is delayed. Close attention to, and therefore prevention of, situations that trigger its recurrence is essential for successful rehabilitation.