3-Foot standing AP versus 45 degrees PA radiograph for osteoarthritis of the knee.

OBJECTIVE: Flexion and erect standing radiographs were evaluated in the current study to compare their sensitivity in detecting articular cartilage wear. DESIGN: Prospective cohort study. SETTING: A tertiary care hospital outpatient orthopedic clinic. PATIENTS: All patients with osteoarthritis of the knee ages 40 to 75 scheduled for arthroscopic debridement between March 1995 and November 1997 were considered for the current study. INTERVENTION: Radiographs were obtained 1 week preoperatively in both the 3-foot standing anteroposterior (AP) and a 45 degrees posteroanterior (PA) flexion weight-bearing projection. Joint space height was measured with a ruler in millimeters at the narrowest point of each compartment. All radiographs were assessed by two independent observers who were blinded to the arthroscopic findings and clinical symptoms of the subjects. MAIN OUTCOME MEASURES: Prediction accuracy of each radiograph for severe Grade IV articular cartilage wear in tibio-femoral compartments. RESULTS: One hundred fifty-two patients with a mean (+/- SD) age of 60.5+/-8.5 years were enrolled in the study. Fifty-one percent were female. Twelve patients were categorized as having severe lateral compartment articular chondropathy (Grade IV) at the time of arthroscopy. The lateral joint space height averaged 1.0+/-1.7 mm SD on the 45 degrees PA radiograph compared with 2.7+/-1.1 mm SD on the 3-foot standing AP view. Using a cutoff of 2 mm or less, the 45 degrees PA view was much more sensitive (83% versus 42%) at correctly detecting the most severe chondropathy. Forty-one patients were classified with severe Grade IV medial compartment chondropathy at arthroscopy. There was little difference in the average joint space height measured by the 45 degrees PA view (1.4+/-1.4 mm SD) or the 3-foot standing AP view (1.9+/-1.6 mm SD). A number of cutoff measures were evaluated, but no significant advantage could be found for either view in evaluating the medial compartment severity. CONCLUSIONS: The bilateral 45 degrees PA is superior for detecting lateral compartment wear but offers no advantage on the medial side. This view should be considered as the screening radiograph of choice in evaluating osteoarthritis of the knee.

Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defects.

Thirty-six patients were treated by Ilizarov transport in conjunction with muscle and myocutaneous flaps coverage. Thirty-one free flaps and 5 rotation flaps were performed. In 13 patients the procedures were carried out in 1-stage or simultaneous manner. In 23 patients, soft tissue coverage proceeded as the initial step followed by Ilizarov reconstruction as a delayed procedure. All flaps survived the simultaneous and delayed procedures and there were no anastomotic complications, but partial flap necrosis occurred in 1 patient 3 months after the index procedure at the time of flap elevation for docking site bone graft placement. The mean segmental defects were 10 cm and 5.8 cm for the simultaneous and delayed groups, respectively. The followup interval from the time of free flap coverage ranged from 2 to 44 months in the simultaneous group with a mean and median of 22 and 24 months, respectively. Twelve patients completed treatment in the simultaneous group with the followup interval from frame removal ranging from 3 to 36 months with a mean and median of 18 and 14 months, respectively. In the delayed group this interval ranged from 1 to 36 months, with a mean and median of 16 and 12 months, respectively, and a mean and median of 24.5 and 21 months, respectively, from the time of the index procedure. Union and absence of infection were achieved in 35 of 36 patients presenting with an acute open fracture, infected nonunion, or aseptic nonunion without stable soft tissue coverage. The Ilizarov fixators remained in place for a median of 9.5 months for the simultaneous group and 8.5 months for the delayed group. When soft tissue defects accompany an infected nonunion or high grade open fracture, the traditional Ilizarov treatment approach of soft tissue recruitment into the wound from the distant corticotomy site is inconsistent with the proven benefit of early soft tissue coverage. The combined approach provides a more reliable soft tissue bed for early cancellous bone grafting of the docking site and permits the accurate restoration of limb length for these very difficult problems.

Management of chronic achilles tendon infection with musculotendinous gracilis interposition free-flap coverage.

Management of infected Achilles tendon repair poses a significant reconstructive problem. Thorough debridement is most important and resection of non-viable tendon substance is required. Reconstruction of such tendon defects requires vascularized soft-tissue coverage that is stable and that offers the possibility of functional restoration. Gracilis free-tissue transfer is an effective means of providing stable, durable, well-vascularized, soft-tissue coverage in an infected Achilles tendon repair. The microsurgical anastomoses are technically straightforward. Cybex II dynomometer measurements, performed 6 months following free-tissue transplantation, revealed strength (torque) and power, at an angular velocity of 45 degrees per second, of: 59 percent and 52 percent, respectively, compared to the uninjured side. Endurance was assessed at an angular velocity of 120 degrees per second over a 15-second test interval, and was noted to be 81 percent, compared to the normal ankle. Excellent functional results and acceptable soft-tissue contour can be expected with this technique.

Soft-tissue reconstruction in orthopedic surgery. Secondary procedures.

The original consulting microsurgeon should be present to assist in the identification and protection of the vascular pedicle during secondary procedures on microvascular transplants. Flap elevation, trimming, and bone graft placement should be completed during a single tourniquet time, whenever possible. Flaps can easily be resutured on the original bed while the tourniquet is still inflated. Although proximal pedicle transection is possible, it should be avoided by careful planning, because the transplanted tissue cannot be predictably expected to survive, especially with muscle transplants. The distal muscle should be transected only in situations in which the muscle inset is extremely complex. Transection in the extramuscular portion of the main pedicle may require prompt microsurgical repair in immature muscle transplants. The safest approach is to avoid the pedicle whenever additional secondary procedures are necessary following free microvascular tissue transplantation. Placement of vascular pedicles such that the anterior crest of the tibia is avoided if the Ilizarov technique is required permit uncomplicated distraction osteosynthesis. Simultaneous Ilizarov fixation and microvascular tissue transfer are safe, practical procedures for limb salvage. Placement of the Ilizarov fixator at the time of microvascular transplantation provides stable fixation and eliminates the need for a subsequent anesthetic for fixator placement. This form of stabilization, when performed at the time of microvascular tissue transfer, allows the orthopedic surgeon direct visualization of the fracture site as the fixator is placed and eliminates the need for placement of the fixation device through the transplanted tissue. Tissue expansion or suction lipectomy are sometimes needed to optimize the clinical result.