Nonoperative treatment of acute anterior cruciate ligament injuries in a selected group of patients.

Conservative treatment of acute anterior cruciate ligament injuries was recommended to selected patients, including those with sedentary occupations, low athletic demands, or ages greater than 30 years. Patients with generalized hyperligamentous laxity were excluded. Fifty-five of 61 patients were available at an average followup of 46 months from the time of initial injury. At followup, giving-way symptoms had not occurred in 23 patients (42%); in 22 (40%) giving way occurred occasionally. Of the 44 patients involved in high- or moderate-demand athletics, 33 (70%) were able to continue with moderate-demand sports. Presence of a medial collateral ligament sprain did not affect the longterm function. Forty-eight percent of the patients scored excellent or good (9 and 18 patients, respectively) on the Hospital for Special Surgery ligament scoring system; 8 (15%) later chose surgical reconstruction. The remaining 47 patients did not believe that their symptoms were severe enough to warrant any further intervention. In a group of individuals who are older and relatively inactive, nonoperative management of anterior cruciate ligament injuries can yield satisfactory results, provided the patients are willing to accept a modest amount of instability and a slight risk of meniscal injury.

Arthroscopic anatomy of the lateral elbow: a comparison of three portals.

Ten fresh cadaveric elbows were used to evaluate the proximity of the radial nerve and its branches to three anterolateral portals. A proximal anterolateral portal used routinely at our institution and located 2 cm proximal and 1 cm anterior to the lateral epicondyle was compared with the distal anterolateral portal described by Andrews and with a mid-anterolateral portal. The three portals were initially established without joint distention while the elbows were flexed 90 degrees. Measurements were then obtained with and without joint distention at flexion angles of 0 degrees and 90 degrees. The radial nerve was found to be an average distance of 3.8 mm at extension and 7.2 mm at 90 degrees of flexion from the distal anterolateral portal, located 3 cm distal and 1 cm anterior to the lateral epicondyle. Conversely, the distance between the proximal anterolateral portal cannula and the nerve was statistically greater (p < 0.05), averaging 7.9 mm in extension and 13.7 mm in flexion. The remaining anterolateral portal, located 1 cm directly anterior to the lateral epicondyle, was found to be at a statistically greater average distance from the nerve than was the distal anterolateral portal but statistically closer than was the more proximal portal. The ability to visualize the joint arthroscopically was assessed using the three portals, and although the ulnohumeral joint could be adequately seen using all portals, radiohumeral joint visualization was most complete and technically easiest using the most proximal portal.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of sectioning of the posterior cruciate ligament and the posterolateral complex on the articular contact pressures within the knee.

Articular contact pressures in ten cadaveric knees with intact ligaments were measured with the use of film and a model that simulated non-weight-bearing resistive extension of the knee. The measurements were repeated after sequential sectioning of the posterior cruciate ligament and the posterolateral complex (the posterolateral capsule, the popliteus muscle and tendon, and the lateral collateral ligament). Patellofemoral pressures and quadriceps load were most significantly elevated after combined sectioning of the posterior cruciate ligament and the posterolateral complex. Medial compartment pressure was significantly elevated after sectioning of the posterior cruciate ligament. The results coincided with, and may partially explain, the clinical findings associated with these types of ligamentous injuries.

T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types.

Forty patients who had a diagnosis of multidirectional instability of forty-two shoulders had a modified Bankart operation in which a T-shaped incision was made in the anterior portion of the capsule, with advancement of the inferior flap superiorly and of the superior flap medially. All of the patients had been injured during athletic activities. Some degree of anterior labral injury was present in thirty-eight of the forty-two shoulders. Half of the patients had generalized ligamentous laxity. The patients were followed for an average of three years (range, two to seven years). Four patients had episodes of instability after the operation. Three had a single episode of posterior subluxation during throwing, one had recurrent posterior subluxation that subsequently was treated by posterior stabilization, and one had anterior subluxation while he was diving from a high board. The average loss of external rotation after the operation was 5 degrees with the arm at the side and 4 degrees with the arm abducted 90 degrees. Satisfaction of the patient was rated excellent for forty (95 per cent) of the shoulders, good for one shoulder, and fair for one shoulder. However, throwing athletes found that they were unable to throw a ball with as much speed as before the operation.

Arthroscopic acromioplasty. Technique and results.

Of forty-four patients who were treated by arthroscopic acromioplasty from July 1984 through August 1986, forty were available for analysis. The average age was 43.2 years, and 86 per cent of them had participated regularly in sports but were disabled due to symptoms of impingement. All patients had had a minimum of six months of non-operative therapy. The final diagnoses, which were based on the findings at arthroscopy and on clinical examination, plain radiographs, and arthrograms, were Stage-II impingement in twenty-four patients, a partial-thickness tear of the rotator cuff in six, and a full-thickness tear of the rotator cuff in ten. The shoulders were scored before the operation and again at follow-up. Preoperatively, thirty-six shoulders were rated as poor and four, as fair. After a minimum follow-up of twelve months (average, seventeen months), the scores had increased in all but one patient. The result was rated good or excellent in twenty-nine (73 per cent) of the forty patients: twenty of the twenty-four who had Stage-II impingement, four of the six who had a partial-thickness tear, and six of the ten who had a full-thickness tear. The over-all average time to return to work was nine days, and the average time to return to sports was 2.4 months. Of the thirty-three patients who had participated in sports, twenty-five (76 per cent) had returned to sports activity at the time of the most recent follow-up. The average time until full recovery was 3.8 months. There were no complications, and, over-all, thirty-eight (92 per cent) of the forty patients were satisfied with the result. In four patients, the result was a failure, and three of the four had a reoperation that relieved the symptoms.

Experimental models to promote healing of tears in the avascular segment of canine knee menisci.

Longitudinal tears were created in canine lateral menisci and techniques were applied to induce healing by removal of a core of tissue from the periphery of the meniscus to the tear or by implantation of a vascularized synovial flap into the tear. The meniscal tears did not heal in knees that were not immobilized, and they healed poorly and sporadically in knees that were immobilized in a cast but bore some weight. However, a higher percentage of tears that were treated by the core-removal or synovial-flap technique healed when the knee was firmly immobilized and weight-bearing was prevented by the use of an external skeletal fixator across the joint for eight to twelve weeks. Neovascularization and access to a source of reparative cells appear to be important in the healing process.

Shoulder arthroscopy for shoulder instability.

The arthroscope is a valuable adjunct in the diagnosis and treatment of shoulder instability. Throwing athletes with shoulder pain, and those with subluxation in particular, may require diagnostic arthroscopy to clarify the instability pattern. Labral debridement, if confined to the portion above the equator of the glenoid, can provide symptomatic relief. Arthroscopic stabilization of the shoulder is still in an evolutionary phase. No long-term data exist as to which technique or material provides the most secure fixation. All of these techniques are technically demanding and require a skilled arthroscopist.

Tips of the trade #5. Shoulder arthroscopy in the seated position.

Shoulder arthroscopy is most commonly performed in some variation of the lateral decubitus position with the arm in traction. Because of reports of neuropraxia associated with the traction, we have investigated the use of the "beachchair" or sitting position for shoulder arthroscopy. We have used this position for over 50 consecutive patients for arthroscopic debridements, arthroscopic subacromial decompressions, and arthroscopic shoulder stabilizations.

Plastic suction tip in anterior cruciate ligament reconstruction.

There are two technical aspects of ACL reconstructive surgery that always present some difficulty. One is determining how much notchplasty is sufficient prior to passage of the graft. The other is passing the suture leader of the graft through the tibial and femoral bone tunnels. We have used a plastic disposable Yankauer suction tip to facilitate both of these tasks.

Shoulder arthroscopy with the patient in the beach-chair position.

We evaluated the use of the beach-chair, or sitting, position for arthroscopic shoulder surgery in 50 consecutive patients. Routine arthroscopy, arthroscopic subacromial decompression, and arthroscopic shoulder stabilizations were performed, with no complications. The advantages of this position include ease of setup, lack of brachial plexus strain because no traction is used, excellent intraarticular visualization for all types of arthroscopic shoulder procedures, and ease of conversion to the open approach if needed. The positioning technique is described.

Arthroscopic treatment of septic knees in children.

Twenty patients were treated for septic arthritis of the knee with arthroscopic lavage (15 patients) or arthrotomy (five patients). Parenteral antibiotics were used in both groups, and both groups did well at follow-up. The advantages of arthroscopic debridement and irrigation over arthrotomy include low morbidity, minimal scarring and much earlier functional recovery (mean 10 days). The advantages over needle aspiration include complete joint visualization, lavage, and easy drain placement allowing suction-irrigation over several days, thus avoiding multiple aspirations. Arthroscopic treatment of knee sepsis in children is simple to perform, is associated with minimal morbidity, and affords excellent long-term results.

Local compression patterns beneath pneumatic tourniquets applied to arms and thighs of human cadavera.

Distributions of tissue fluid pressure were examined beneath a standard pneumatic tourniquet in six upper extremities and six lower extremities of fresh human cadavera, disarticulated at the shoulder and hip, respectively. A standard 8-cm-wide tourniquet cuff was applied at mid-humerus or mid-femur position. Tissue fluid pressures were measured by 100-cm-long slit catheters inserted parallel to the bone at four tissue depths: subcutaneous, subfascial, mid-muscle, and adjacent to bone. All arms and thighs were studied at the following cuff pressures: 100, 150, 200, 250, 300, 400, and 500 mm Hg. Tissue fluid pressure was always maximal in subcutaneous tissue at mid-cuff. Transmission of cuff pressures to deeper tissues was significantly less (p less than 0.01) in the thighs with a girth of 40-52 cm than in the arms with a girth of 22-33 cm. At the four tissue depths studied, tissue fluid pressures fell steeply in a longitudinal direction near the cuff edge to levels near zero at points 1-2 cm outside each cuff edge. Our results suggest that wider cuffs are required on thighs than on arms to provide a bloodless field during limb surgery and to minimize underlying tissue injury associated with high cuff pressures. Our recommendation for wider tourniquet cuffs than those presently used during orthopaedic surgery is contrary to recent prevailing knowledge.

Increased transsynovial transport with continuous passive motion.

Thirteen freshly killed immature rabbits were used to study the effect of continuous passive motion (CPM) on regional nutritional pathways of the medial and lateral menisci and the transport of a solute from synovial fluid to the patellar tendon. A bolus of 35SO4 was injected into each knee joint cavity. The right knee underwent CPM for 1 h, whereas the left knee was immobilized (rest extremity). Both knees were then rapidly resected and immediately frozen. The medial and lateral menisci were removed and sectioned into anterior, middle, and posterior thirds for Group 1 animals; in Group 2 animals a portion of patellar tendon was harvested. Radioactivity as counts per minute per milligram of tissue was counted in a scintillation counter. The posterior portion of the lateral meniscus in the rest extremity had significantly higher uptake than the extremity that underwent CPM (p less than 0.001). In the extremity at rest, the posterior third of the lateral meniscus had a significantly higher uptake than that of the middle third (p = 0.04). In Group 2 rabbits, the patellar tendon of the knee undergoing CPM had significantly higher uptake as compared with the patellar tendon of the knee at rest (p = 0.02). These results indicate that diffusion from synovial fluid to meniscal cells is an important mechanism of transport for low-molecular-weight nutrients such as sulfate; CPM does not facilitate this mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperbaric oxygen reduces edema and necrosis of skeletal muscle in compartment syndromes associated with hemorrhagic hypotension.

This study examined the effect of exposures to hyperbaric oxygen on the development of the edema and necrosis of muscle that are associated with compartment syndromes that are complicated by hemorrhagic hypotension. A compartment syndrome (twenty millimeters of mercury for six hours) was induced by infusion of autologous plasma in the anterolateral compartment of the left hind limb of seven anesthetized dogs while the mean arterial blood pressure was maintained at sixty-five millimeters of mercury after 30 per cent loss of blood volume. These dogs were treated with hyperbaric oxygen (two atmospheres of pure oxygen) and were compared with six dogs that had an identical compartment syndrome and hypotensive condition but were not exposed to hyperbaric oxygen. Forty-eight hours later, edema was quantified by measuring the weights of the muscles (the pressurized muscle compared with the contralateral muscle), and necrosis of muscle was evaluated by measuring the uptake of technetium-99m stannous pyrophosphate. The ratio for edema was significantly (p = 0.01) greater in dogs that had not been exposed to hyperbaric oxygen (1.15 +/- 0.01) than in the dogs that had been treated with hyperbaric oxygen (1.01 +/- 0.03), and the ratio for necrosis of muscle was also significantly (p = 0.04) greater in dogs that had not had hyperbaric oxygen (1.96 +/- 0.41) than in those that had been treated with hyperbaric oxygen (1.05 +/- 0.11). Comparisons were also made with the muscles of four normal control dogs and separately with the muscles of six normotensive dogs that had an identical compartment syndrome and normal blood pressure and were not treated with hyperbaric oxygen.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of conventional radiography and computed tomography in the evaluation of spiral fractures of the tibia.

Spiral fractures of the distal third of the tibial shaft can have problems of malunion or non-union that may be related to inability to assess the quality of the initial reduction of the fracture. We created typical two-fragment torsional tibial fractures in cadaver bones. The fracture fragments were mounted in a specially constructed jig that allowed simulation of various malreduction positions including varus and valgus angulation, antecurvatum, recurvatum, malrotation, and shortening. Anteroposterior and lateral radiographs and computed tomographic scans of the specimens were made. Measurements of the fracture gap were made at defined distances along the fractures, directly on the specimens as well as on the radiographs and computed tomographic scans. Excellent correlation was obtained between measurements of the gap on the specimens and on the computed tomographic scans, but plain radiographic measurements in thirty of thirty-four instances underestimated the true width of the gap. When shortening was introduced larger maximum gaps (of as much as eighteen millimeters) as well as greater discrepancies between measurements on the scans and plain radiographs were seen. The sizes of the fracture gaps were also greater for a given degree of shortening when the pitch of the spiral fracture was greater.

Nutrition of the anterior cruciate ligament. Effects of continuous passive motion.

Twelve freshly killed mature male rabbits were used to study the effects of continuous passive motion (CPM) on regional and overall nonvascular nutritional pathways of the anterior cruciate ligament (ACL). One hundred fifty microcuries of 35sulphate was injected intraarticularly into each knee joint. The right knee underwent CPM for 1 hour, while the left knee remained immobilized. Both knee joints were then isolated and immediately frozen. The ACLs were removed while still mostly frozen, and sectioned into anterior, middle, and posterior thirds for the six rabbits in Group 1, and proximal, middle, and distal thirds for the six rabbits in Group 2. In addition, quadriceps tendon samples were harvested from each limb of three rabbits. After appropriate processing, all samples were counted in a scintillation counter, and counts per minute per milligram of tissue were calculated. There was significantly higher uptake in rest extremity ACLs compared to CPM extremity ACLs (P = 0.0001). No significant difference was demonstrated in regional uptake comparing respective thirds of the ACL in either Group 1 or Group 2. Quadriceps tendon uptake trended higher in the limbs exposed to CPM compared to those maintained at rest (P = 0.14). The ACL uses diffusion as a primary nutrient pathway. CPM does not increase nutrient uptake by the ACL in this avascular model, but CPM may facilitate transport of metabolites out of the joint. No regional differences in uptake within the ACL occurred in either group.

Growth and development of the tibia, fibula, and ankle joint.

Deformities of the leg and ankle may result from growth abnormalities of the tibia and fibula. Measurements of the distance between the proximal tibial and fibular physes, the distal tibial and fibular physes, and the angle between the long axis of the tibia and the distal tibial physis and talar dome were made to determine the changes that occur during normal skeletal development. These measurements demonstrate that early detection of growth discrepancy is possible.