Safe parameters for laser chondroplasty of the knee.

BACKGROUND AND OBJECTIVE: The purpose of this study is to summarize our use of the Holmium laser as a tool in performing chondroplasties of the knee and to determine whether any untoward affects developed at the site of laser application. STUDY DESIGN/MATERIALS AND METHODS: A retrospective review of 504 laser chondroplasties of the medial femoral condyle was done. Laser parameters and the average number of joules to perform the chondroplasties were recorded. The average follow-up was 11 months. RESULTS: Preoperative MRI interpretation indicated that 8% of the patients had osteonecrosis prior to surgery. 88% of the patients were satisfied with the procedure. All failures were evaluated by X-ray, MRI, bone scan, or biopsy of the medial femoral condyle. No new cases of osteonecrosis were determined. CONCLUSION: No new cases of osteonecrosis were documented of the medial femoral condyle following laser chondroplasty utilizing the parameters in this study. The Holmium laser remains a safe and efficacious tool in performing chondroplasty.

Posterior tibial tendon dysfunction.

Posterior tibial tendon dysfunction, a common entity, frequently is unrecognized and inappropriately managed. Acutely, pain and swelling are present over the medial ankle and longitudinal arch. Long-standing inflammation can lead to tendon rupture, resulting in a progressive planovalgus or "flat foot" deformity. Plain radiographs illustrate the changes in bony anatomy associated with chronic posterior tibial deficiency, while magnetic resonance imaging scans can identify the three stages of posterior tibial tendon pathology. Most cases are amenable to conservative therapy, including rest and administration of nonsteroidal antiflammatory agents. Often a short period of immobilization in a cast or the use of an orthosis is beneficial. In cases with persistent tenosynovitis, complete tendon rupture, or progressive deformity, surgical intervention is indicated.

Bone signal abnormalities in the posterolateral tibia and lateral femoral condyle in complete tears of the anterior cruciate ligament: a specific sign?

Thirty-two patients with acute, complete tears of the anterior cruciate ligament (ACL) proved at surgery underwent examination with magnetic resonance (MR) imaging. Bone impaction sites were present in the posterolateral tibial plateau in 30 patients (94%) and in the lateral femoral condyle (LFC) in 29 patients (91%). The bone abnormalities had low signal intensity on T1-weighted images and high signal intensity on T2-weighted images when compared with the signal intensity of normal marrow. It is assumed that the bone changes occur during injury when the LFC impacts into the posterior tibia, either during the initial rotary subluxation or as the LFC recoils to return to anatomic alignment. Only one of six partial ACL tears had a bone signal change. In patients with acute knee injury, bone impaction sites in the posterolateral tibia and the LFC suggest that a complete ACL tear is present.

Distal oblique osteotomy for tailor's bunion.

Thirty-six patients with a total of 50 symptomatic tailor's bunions were evaluated clinically, radiographically, and subjectively, both before and after a distal oblique osteotomy procedure was performed. Thirty-four of 36 patients were satisfied with pain relief. Radiographic measurements derived from this study were consistent with those of other studies. Avascular necrosis, nonunions, or neuroma formation were not encountered in this study. The significant advantages of this procedure are its simplicity, safety, and predictability. The procedure does not require internal fixation or postoperative immobilization.

Preliminary report: modifications of the Regnauld osteochondral autogenous graft.

The enclavement procedure was originally described by Bernard Regnauld in 1968. The basal portion of the proximal phalanx of the hallux is used as an osteochondral autogenous graft in the treatment of hallux limitus, hallux rigidus, and hallux valgus. This paper presents a review of Regnauld's techniques, emphasizing an in situ modification of the inverted graft that allows for greater technical ease, increased stability, and improved graft viability, with more rapid incorporation.

Prepatellar bursitis: a complication of arthroscopic surgery of the knee due to a lost meniscal fragment.

The case report of a patient with prepatellar bursitis resulting from a retained meniscal fragment following arthroscopic surgery is presented. The potential for the development of this condition is explained based on the anatomic position of the prepatellar bursa and its relationship to the arthroscopic portals.

The forward elevation maneuver for reduction of anterior dislocations of the shoulder.

The simplicity, safety, and physiologic nature of the forward elevation maneuver for reductions of anterior dislocations and fracture-dislocations of the shoulder, is illustrated in a report of 50 cases. The method is effective and free of complications. The maneuver requires very little, if any, sedation and is particularly useful in all well-muscled young athletes with anterior dislocations of the shoulder.

The role of incompetence of the anterior cruciate and lateral ligaments in anterolateral and anteromedial instability. A biomechanical study of cadaver knees.

UNLABELLED: The anterolateral and anteromedial stability of seventeen fresh frozen cadaver knees was studied in a test apparatus designed to simulate physiological conditions. Statistically significant increases in internal rotation occurred in seven knees when only the anterior cruciate ligament was sectioned, and these increases were enhanced by subsequent sectioning of the posterolateral complex and the lateral collateral ligament, singly or in combination. On the other hand, sectioning of the posterolateral complex and of the lateral collateral ligament, leaving the anterior cruciate intact, did not produce significant increases in internal rotation until the anterior cruciate ligament was sectioned in seven knees. When the entire anterolateral capsule was sectioned as far posterior as the lateral collateral ligament in three knees, no changes in internal or external rotation occurred. Only when the posterolateral complex was sectioned was there a significant increase in external rotation in any of the ligament-sectioning sequences. Thus, it appears that for pathological internal rotation of the tibia on the femur to occur, the anterior cruciate ligament must be incompetent. CLINICAL RELEVANCE: The test apparatus and the results are useful in assessing which ligament structures contribute to clinically noted rotational knee instabilities.

Extraarticular steroid injection for hand and wrist disorders.

Extraarticular injection of steroid often relieves symptoms in noninfectious inflammatory disorders of the hand and wrist that have not responded to other forms of treatment. The technique is simple and does not require specialized equipment. Complications, including infection, are practically nonexistent.

Extraarticular synovial chondrometaplasia: locking of the proximal interphalangeal joint of the finger.

A case of extraarticular synovial chondrometaplasia at the proximal interphalangeal joint level with intermittent locking of the ring finger is presented. The characteristics of extraarticular synovial chondrometaplasia of the acral parts are reviewed.

Efficacy of various forms of fixation of transverse fractures of the patella.

To determine whether any of the commonly used wiring techniques are rigid enough to allow early motion in the treatment of transverse fracture of the patella, the patellae of twenty-five fresh cadaver knees were fractured transversely and fixed using the following techniques: circumferential wiring, tension-band wiring, Magnusson wiring, and a modification of tension-band wiring. The knees were mounted in a machine capable of measuring quadriceps force, flexion angle, and fracture separation simultaneously. The knees were extended from 90 to zero degrees by applying tension to the quadriceps tendon with the force of gravity as the only resistance, and separation of the fracture fragments was measured first with the retinaculum unrepaired and then again with the retinaculum repaired. Separation of the fracture fragments was much less with the Magnusson wiring and modified tension-band wiring than with circumferential wiring or standard tension-band wiring. The retinacular repair was found to contribute to stability; however, this seemed most important in the less rigid repairs. We concluded that if early motion is to be used in treating transverse fractures of the patella, techniques in which the wire is anchored directly in bone should be used and the retinaculum should be repaired.

Whiplash syndrome.

Whiplash, or cervical acceleration extension injury, is due predominantly to hyperextension and prolongation of the neck, with rebound flexion. A variety of disabling soft tissue injureries may result, including vertebral arter damage. While x-rays are generally unremarkable, they should be obtained. Rational management is based on rest, heat and analgesics, muscle relaxants, isometric exercises and an informed patient. The assumption that whiplash syndrome occurs only in neurotic or litigation-minded patients should be discouraged.

Arthroscopy of the knee.

Fiberoptics permit a minimally invasive direct inspection of the knee joint. Arthroscopy is indicated when no definitive clinical diagnosis can be made. An organized approach includes inspection of the suprapatellar pouch, the articular surfaces of the patella, the medial and lateral compartments of the knee and the intercondylar area. Common afflictions diagnosed by arthroscopy include chondromalacia, meniscal lesions, osteoarthritis, cruciate ligament injuries, chronic synovitis and loose bodies. Complications and morbidity are minimal.