Osteochondral lesions of the talus.

We report demographic, clinical, and imaging data on 92 patients with osteochondral lesions of the talus collected in one center between 1981 and 1992. All patients reported pain as their primary symptom. Ninety-four percent of the patients reported pain with activity. Physical examination was unhelpful. Using newer imaging techniques (bone scan and computed tomography) and with increased awareness, we have observed a sevenfold increase in the diagnostic frequency of osteochondral lesions of the talus between the years 1981 to 1986 and 1987 to 1992. Bone scan is an excellent screening tool for patients with chronic ankle pain and has 99% sensitivity in depicting osteochondral lesions. Computed tomography demonstrated a previously unclassified lesion, the radiolucent defect, which accounts for 77% of the lesions in this series. We have therefore modified the Berndt and Harty classification system, basing it on radiographic appearance (principally computed tomography) and adding the radiolucent lesion. Fifty-eight patients were treated surgically. Anterior and midtalar lesions are now approached arthroscopically. Surgical treatment of the radiolucent lesion, consisting of curettage and drilling, gives 42% excellent and 32% good results. Pain relief often occurs within months of surgery, but healing of the lesion requires years, and some may persist indefinitely.

The role of bone scintigraphy in the evaluation of talar dome fractures.

We undertook a retrospective study of 122 patients with ankle pain to determine the accuracy of bone scintigraphy using 99mTc-methylene diphosphonate (MDP) for detection of osteochondral talar dome fractures (OCTDF). Plain radiographs, which were available in 97 patients, had not revealed any abnormality in the talar dome. Bone scintigraphy was followed by CT, which was considered to be the reference test in diagnosing OCTDF. Analysis of our data showed that when the bone scan findings in the two highest confidence categories (high and moderate probability) were accepted as abnormal, the sensitivity and the specificity of the test were 0.94 and 0.76, respectively. Although CT is mandatory to establish the stage of OCTDF, it cannot be used routinely due to its high cost. Bone scintigraphy appears to be a good screening procedure that will identify patients who are likely to benefit from further radiographic studies such as CT. These findings are subject to further confirmation in a prospective study.

A test for knee posterolateral rotatory instability.

A test for knee posterolateral instability, which is a modification of the standard posterolateral rotatory instability test, is described. In this test, the patient lies supine on the examination table with hips and knees flexed to 90 degrees. The examiner grasps both feet and attempts to maximally externally rotate them. A positive test is indicated by (1) excessive external rotation of the affected tibia, which is easily recognized since the feet act as pointers and amplify the external rotation, and (2) a slight posterior sag of the affected tibial tubercle, which is more subtle but still a very recognizable sign.

Anatomy of the axillary nerve and its relation to inferior capsular shift.

Axillary nerve injury is a recognized complication of the capsular slide procedure for multidirectional instability of the shoulder. Axillary nerve dissection followed by an anterior or posterior capsular shift procedure was carried out on 12 autopsy subjects to observe: (1) the normal relationships of the nerve; (2) its proximity to structures dissected in the procedure; and (3) the effects upon it of both anterior and posterior capsular shift procedures. The axillary nerve arises immediately posterior to the coracoid process and conjoint tendon. It crosses the inferolateral border of the subscapularis 3 to 5 mm medial to its musculotendinous junction, and it lies in intimate contact with the inferior capsule as it passes through the quadrilateral space. The nerve should be visualized prior to transecting the subscapularis tendon. During detachment of the inferior capsule from the humeral neck, the humerus should be gradually externally rotated, and the nerve should be gently retracted with a small flat instrument. Sutures reattaching the flap should be carefully placed to avoid injuring the nerve. The tendinous insertion of the teres minor is preserved from a posterior approach. The nerve can be visualized and protected during capsular detachment.

A modified Bankart procedure for recurrent anterior/inferior shoulder instability. A preliminary report.

A modified Bankart procedure has been developed using a single interosseous extraarticular suture to correct the Bankart lesion and a longitudinal capsular incision to prevent capsular shortening and allow for performance of an anterior capsular shift. Its purpose is to allow full functional return in the active athletic population while controlling anterior/inferior instability. Followup of the first 30 patients on whom we used the procedure shows excellent postoperative range of motion (average loss: 2 degrees of flexion, 1 degree of abduction, 4 degrees of external rotation in adduction, and 7 degrees of external rotation in abduction) and return to sports (90%, of which 70% returned to their previous level). There is, however, an unacceptably high recurrence rate of 13%, all of which occurred early in the series. Technical refinement and experience have apparently reduced the recurrence rate without sacrifice of range of motion or functional ability.

Cysts of the lateral meniscus: arthroscopy versus arthroscopy plus open cystectomy.

A retrospective analysis was performed on 32 knees in 31 patients with the diagnosis of cyst of the lateral meniscus. Average follow-up was 41 months, with a range of 16-72 months. Surgical and histological examination demonstrated pathology varying from large meniscal tears with minimal cyst formation to large cysts with no demonstrable meniscal tear. Two theories of etiology emerged: (a) The tear begins in the meniscus and spreads through the periphery. (b) The lesion begins as a compression injury to the vascular periphery and spreads centrally, producing a meniscus tear, or peripherally, producing a cyst, or both. In our series, 20 patients managed by arthroscopic partial meniscectomy and open cystectomy had 80% excellent-good results versus 50% excellent-good results in 12 patients treated with arthroscopy and partial meniscectomy without extraarticular cystectomy. We recommend the following treatment: arthroscopy with a diligent search for a lateral meniscal tear, especially peripherally. If none is found, proceed to extraarticular cystectomy. If a tear is found, remove all unstable meniscal fragments, leaving a rim, if possible, especially adjacent to the popliteus recess, and then proceed to open cystectomy.

Shoulder girdle dysplasia associated with nail patella syndrome. A case report and literature review.

Hereditary oncycho-osteodysplasia is a well-defined clinical entity consisting of four characteristics: (1) complete or partial absence of finger and thumb nails typically more severe on the radial side of the hand; (2) bony dysplasia about the knee consisting of patellar and lateral femoral condylar hypoplasia; (3) bony dysplasia about the elbow consisting of hypoplasia of the capitellum and radial head; and (4) iliac horns. The hereditary pattern is autosomal dominant with complete penetrance and variable expressivity. Other associated dysplasias have been reported, but there are only six articles reporting shoulder dysplasia and some of these are of questionable validity. This article reports the clinical and roentgenographic findings of a patient with an obvious deformity of the scapula consisting of a small acromion in both the anteroposterior (AP) and lateral planes. The acromion was deformed and slanted upwards at the lateral border. A slightly attenuated glenoid pointed laterally or slightly inferiorly, giving a humeral acromial interval of 2.5 cm.

Anterior compartment syndrome in a patient with fracture of the tibial plateau treated by continuous passive motion and anticoagulants. Report of a case.

Open reduction and internal fixation with anterior compartment fasciotomy for fractures of both tibial plateaus in a 36-year-old woman was complicated by deep-vein thrombosis three days after surgery. After establishing anticoagulation, continuous passive motion (CPM) was instituted. Twenty-four hours after the commencement of CPM, an anterior compartment syndrome developed. A second operation revealed a large hematoma within the anterior compartment musculature, the development of which appeared to be the result of the combination of continuous passive motion and anticoagulation therapy in a seriously injured limb. In this clinical condition, especially close observation for the development of signs of elevated intracompartmental pressure is mandatory.

Osteochondral lesions of the talus in a sports medicine clinic. A new radiographic technique and surgical approach.

A retrospective review of 11 patients seen at the University of British Columbia Sports Medicine Clinic with osteochondral lesions of the talus was undertaken. From our data, a number of points became apparent. There was a predominance of posteromedial talar dome lesions. A flexion-inversion ankle injury could be documented in the majority of cases. There was frequently a long delay in diagnosing these ankle sprain mimics. Historical details which should raise one's index of suspicion include: (1) history of flexion-inversion injury; (2) exercise-related ankle pain; (3) sensations of "clicking and catching"; and (4) persistent swelling. Surgery produced consistently good early results in these active patients without osteotomizing the medial malleolus. Experimental analysis and clinical experience suggest that the optimal radiographic technique for identifying the posteromedial osteochondral lesion consists of an anteroposterior view of the ankle in maximum plantar flexion with the kilovoltage set at 70.

Elbow injuries in athletes.

Throwing and racquet sports produce large stresses at the elbow joint consisting of tension on the medial or ulnar side, and compression on the lateral or radial side. Medial tension can lead to tears of the common flexor origin or medial collateral ligament, ulnar nerve subluxation, or pronator teres syndrome. Bony lesions include fragmentation and partial avulsion of the medial humeral epicondyle (little league elbow) or even complete avulsion of the epicondyle. The possible sequelae of excessive lateral compression include osteochondritis dissecans of the capitellum, osteochondral fractures of the capitellum and radius, and loose bodies. Early and accurate diagnosis is essential to initiate proper treatment.

Plating of femoral shaft fractures: the Vancouver experience.

UNLABELLED: A retrospective study of 46 femoral shaft fractures treated with A.O. compression plating by eight surgeons of varying expertise in A.O. techniques at two large trauma hospitals was undertaken. Information was gained from hospital and office records, X-rays , operative summaries, and personal interview and examination. Average followup was 3 years. There was a 24% complication rate including failure of plates and screws, refracture after plate removal, fracture near the end of the plates, nonunion, and infection. Average time to union was 7 months. Despite less than optimal surgical technique, excellent or good results were obtained in 88% of all patients and 100% of those patients who did not have complications. CONCLUSIONS: 1) This is an acceptable method of treating femoral shaft fractures which are not amenable to I.M. nailing providing: the A.O. techniques are strictly adhered to; bone grafts are used when there is loss of bone, less than anatomic reduction and rigid internal fixation, and or devascularized bone; the patient is followed with partial weight bearing and cast brace if necessary until healed; plate is left in situ 1 year following union; and 2) all surgeons using the A.O. technique should be aware of the necessity of anatomic reduction and rigid internal fixation, and trained in its use.

Non-union in fractures of the humeral shaft.

Twenty-nine patients with non-union of the humeral shaft, who were treated in 3 major Vancouver hospitals, were studied. Reasons for non-union, effectiveness of various treatment methods, and complications are discussed. Fractures occurring in the middle third of the humeral shaft, comminuted or open fractures and those treated early by open reduction, are more prone to non-union. Nearly 50% of the patients with non-union were chronic alcoholics. Compression plating with cancellous bone grafting gave the best rate of healing. However, both early and late operative treatment gave a relatively high complication rate.

Arterial plasma amino acids in patients with serious postoperative infection and in patients with major fractures.

Arterial plasma amino acids were measured in 27 patients with serious septic complications after operation, 15 patients following reduction of femoral shaft fractures and nine control patients on the first and third days following uneventful major abdominal surgery. Amino acid concentrations in the controls were similar to those which have been reported during early starvation. The amino acid patterns seen in all groups did not resemble that previously observed following glucocorticoid administration. In the patients with infection, mean phenylalanine concentration (108.0 +/- 46.9 mumoles per liter) was significantly greater than in the controls on the first (p greater than 0.001) or third (p less than 0.001) postoperative days. Four of the septic patients with hyperphenylalaninemia also had elevated arterial methionine concentrations. These observations suggest that many of the patients with sepsis had seriously impaired liver metabolism. In patients with fractures, the concentrations of ornithine (p less than 0.001), taurine (p less than 0.05), and aspartic acid (p less than 0.05) were lower than in controls. No other significant differences of amino acid concentrations were observed. It is difficult to relate these differences to a specific metabolic abnormality.