ABSTRACT
PURPOSE OF THE STUDY: Comparisons have been often made between bone-tendon-bone plasty and hamstring tendon four-strand plasty. Whether a lateral tenodesis should be associated with the intra-articular reconstruction and the appropriate time between the accident and the repair remain two topics of debate. We present results obtained in a consecutive series of 50 pivoting sport atheletes reviewed retrospectively. These patients had been treated within eight days of trauma with a modified MacIntosh technique using an iliotibial band. This technique enables lateral tenodesis and reconstruction of the central pivot with only one harvesting site. We searched for responses to two questions: are our results comparable to those in other published series? could this operation be warranted as an emergency procedure? MATERIAL AND METHODS: Fifty patients from a consecutive retrospective series of 62 patients (eight lost to follow-up and four excluded from the analysis) were reviewed by an independent observer at mean follow-up of 5.2 years (range 54.4 to 86.4 months). The ARPEGE and IKDC scoring systems were used. An isokinetic assessment was obtained in 38 patients at one year. The reconstruction technique used an iliotibial band measuring 40-45 mm in width. The lateral reconstruction consisted in section then translation of the lateral intermuscular partition. RESULTS: The overall outcome was scored as follows: IKDC A 38%, B 46%, C 12%, D 4%. Mean residual differential laxity (KT 1000) was 1.86+/-1.74 assessed manually with a negative Lachman in 48% of knees. 88% of the positive tests had been neutralized. Early anatomic failure was noted in two knees with recurrent traumatic tears at 25 and 38 months. Using the ARPEGE scoring system, outcome was excellent in 38%, good in 46%, fair in 12% and poor in 4%. At last follow-up, the level of sports activities was unchanged in 33 patients. Irreducible flexion measuring more than 5 degrees was noted in two patients, and a deficit in flexion greater than 20 degrees in three. One female athlete who had resumed her former sports level presented mobilization under narcosis. None of the patients complained of pain at the harvesting site. There was one case of muscle herniation proximally by wound dehiscence. Mean residual deficit of the quadriceps, measured at twelve months, was 10% at 90 degrees /s; mean residual deficit of the hamstrings at the same speed was 1.3%. DISCUSSION: Our overall results as measured with the IKDC scoring system were comparable with those observed in series using other autologous transplants. The risk of stiffness is greater with early reconstruction, suggesting emergency repair should be considered with caution. Recovery of muscle force demonstrates one of the advantages of using the iliotibial band which does not injure the extensor-flexor system of the knee joint. The fact that none of the patients complained of pain at the harvesting site is a favorable element for rehabilitation and resumed sports activities.
Subject(s)
Anterior Cruciate Ligament Injuries , Anterior Cruciate Ligament/surgery , Athletic Injuries/surgery , Tendons/transplantation , Adolescent , Adult , Female , Follow-Up Studies , Humans , Male , Orthopedic Procedures/methods , Retrospective Studies , Time FactorsABSTRACT
PURPOSE OF THE STUDY: Spinal fractures in patients with ankylosing spondylitis or idiopathic skeletal hyperostosis can raise difficult diagnostic and therapeutic problems. Spinal fracture is well known in ankylosing spondylitis but exceptional in diffuse idiopathic skeletal hyperostosis. The purpose of the present work was to identify clinical and radiological features in patients with ankylosing spondylitis, to determine whether similar risks and clinical expression are observed in patients with diffuse idiopathic skeletal hyperostosis, and to present a radiological classification of these fractures. We did not assess therapeutic methods in the present study. MATERIAL AND METHODS: Forty-eight fractures in 48 patients were observed over a period of 17 years. Twenty patients (mean age 62 years) had ankylosing spondylitis and 28 patients (mean age 81 years) had diffuse idiopathic skeletal hyperostosis. A fall was the immediate cause of the fracture in more than half of the patients. No notion of trauma could be identified in six patients. The radiological classification was established as follows; type I open-wedge anterior fracture, type II "sawtooth" fracture, type III occult or radiologically invisible fracture, type IV non-specific fractures comparable to other spinal fractures. A computed tomography was obtained in all patients seen after 1992 and magnetic resonance imaging was performed in case of suspected extradural hematoma. The ASIA classification (as modified by Frankel) was used for cord injuries. Clinical course and complications were noted. RESULTS: Diagnosis was established the day of fracture in 32 patients (12 spondylitis and 20 hyperostosis) and between day 2 and 30 for 16 (8 spondylitis and 8 diffuse idiopathic skeletal hyperostosis). The radiological classification was: type I n=30, type II n=4, type III n=8, type IV n=6 (one odontoid fracture, five compression fractures). Three patients had extradural hematomas (2 spondylitis and 1 hyperostosis). Thirty-four patients (11 spondylitis and 23 hyperostosis) had cord injuries, including 16 with a symptom-free interval. The ASIA classification was: type A n=4, type B n=6, type C n=20, type D n=4. Thirty-two patients died within the first three months after spinal fracture (10 spondylitis and 22 hyperostosis), due to bed rest related complications in 30. One patient died after rupture of an aortic aneurysm. DISCUSSION: Spinal fractures in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis generally occur spontaneously or after low-energy trauma. Subsequent complications have serious consequences. Late diagnosis either results from missing a radiologically visible fracture or from the presence of an occult "paper thin" fracture. We do not have experience with diagnostic scintigraphy or magnetic resonance imaging. In our opinion, repeating standard x-rays the second and third weeks and use of a spiral scan or multiple spiral scan could provide early diagnosis. CONCLUSION: The possible diagnosis of spinal fracture should be explored very extensively in patients with a symptomatic ankylosed spine who present symptoms compatible with spinal fracture, with or without trauma.
