Harris lines of the tibia across centuries: a comparison of two populations, medieval and contemporary in Central Europe.

OBJECTIVE: To determine the incidence of Harris lines in two medieval populations which inhabited the Canton of Berne, in Central Switzerland, and to compare the results with those of a contemporary population living in the same geographical area. A simplified method is described for measuring the age of the individual at the time of formation of Harris lines, with possible future applications. DESIGN AND PATIENTS: Radiographs of 112 well-preserved tibiae of skeletons of two medieval populations from the eighth to fifteenth centuries were reviewed for the incidence of Harris lines. The results were compared with those of 138 current patients living in the same geographic location in Central Switzerland. Age and gender of the medieval individual were determined using known anthropological methods. Age of bone at the time of formation of Harris lines was estimated according to the method of Maat. RESULTS: Harris lines were found in 88 of 112 (80%) of the examined medieval skeletons and in 28 of 138 (20%) of the living individuals. Higher incidences of Harris lines were found at the age of 2 years and at ages between 8 and 12 years in both populations. No gender difference was found regarding the incidence of Harris lines. In both populations the occurrence of Harris lines was associated with certain diseases such as degenerative bone disease, trauma, osteoporosis, rheumatoid arthritis, peripheral vascular diseases, rickets and bony deformities. CONCLUSION: A high incidence of Harris lines was found in the medieval population, perhaps reflecting difficult living and hygienic conditions, but also the poor care and neglect of the children population. Measuring the age of the individual at the time of formation of Harris lines is simple and may have future clinical applications in the paediatric population for medico-legal purposes. The application of Harris lines as a marker in follow-up of osteoporosis may need further evaluation.

Shoe rim and shoe buckle pseudotumor of the ankle in elite and professional figure skaters and snowboarders: MR imaging findings.

OBJECTIVE: To review MR imaging of figure skaters and snowboarders presenting with painful soft-tissue swelling of the lateral supramalleolar region with a clinical provisional diagnosis of soft-tissue tumor. DESIGN AND PATIENTS: MR imaging was prospectively reviewed by two sub-specialized musculoskeletal radiologists. The findings were correlated with a second clinical review and examination of the shoe wear. The patients were four female athletes undergoing heavy training regimes, ranging in age between 16 and 25 years. Two patients were elite figure skaters, and two were professional snowboarders. Three patients had unilateral masses with pain, and one patient presented with bilateral clinical findings. RESULTS: MR imaging showed subcutaneous, focal soft-tissue masses of the supramalleolar region in five ankles at the same level above the ankle joint. MR imaging prompted a second clinical review and correlation with the shoe wear. The MR imaging findings correlated to the level of the shoe rim or shoe buckle in all patients, confirming the suspected MR imaging diagnosis of an impingement syndrome. All four sportswomen were training excessively, ignoring safety advice regarding training duration, timing of breaks, and shoe wear rotation. CONCLUSION: Ice skaters and snowboarders may present with persistent and disabling pain. On MR imaging, this corresponds to a focal soft-tissue abnormality, which may be due to subcutaneous fat impingement between the fibula and the shoe rim or shoe buckle.

Postpartum osteoporosis associated with proximal tibial stress fracture.

A 33-year-old woman presented with acute nonspecific knee pain, 6 months postpartum. MR imaging, computed tomography and radiography were performed and a proximal tibia plateau insufficiency fracture was detected. Bone densitometry demonstrated mild postpartum osteoporosis. To our knowledge these findings have not been described in this location and in this clinical setting. The etiology of the atraumatic fracture of the tibia is presumed to be due to a low bone mineral density. The bone loss was probably due to pregnancy, lactation and postpartum hormonal changes. There were no other inciting causes and the patient was normocalcemic. We discuss the presence of a postpartum stress fracture in a hitherto undescribed site in a patient who had lactated following an uncomplicated pregnancy and had no other identifiable cause for a stress fracture.

MR imaging of calcification of the lateral collateral ligament of the knee: a rare abnormality and a cause of lateral knee pain.

OBJECTIVE: Our objective was to describe the radiologic appearances of calcification of the lateral collateral ligament (LCL) of the knee in four patients who presented with acute atraumatic lateral knee pain. This rare abnormality has not, to our knowledge, been previously shown on MR imaging. CONCLUSION: Calcification of the LCL of the knee is a rare cause of lateral knee pain and is thought to reflect underlying hydroxyapatite deposition. On MR imaging, calcification of the LCL may be associated with an aggressive appearance that can be mistaken for other knee abnormalities.

Observations on retrieved glenoid components.

To obtain more information on the pattern of damage of prosthetic glenoid components, we analyzed 7 retrieved glenoid components. The consecutive series included 2 standard polyethylene components and 5 highly crystalline polyethylene glenoids (Hylamer; DePuy Dupont Orthopaedics, Warsaw, IN) retrieved 3 to 12 years after implantation. At revision, 4 of 5 Hylamer components were fractured. Common wear patterns were i) deformation and crumbling of the rim, particularly at the inferior hemicircumference, probably caused by direct contact of the humerus with the prosthetic component; ii) roughening (abrasion and scratching) of the adjacent articulating surface; and iii) concentric and congruous wear centered posteriorly. Available glenoid components may cover an excessive sector of the head. This can result in mechanical restriction of glenohumeral motion and abutment of the humerus against the glenoid rim. Abutment may cause major shear forces and therefore cause glenoid loosening. The value of articular surface mismatch is questionable because retrieved glenoids were worn to a conforming joint.

Surgical landmarks to determine humeral head retrotorsion for hemiarthroplasty in fractures.

Malrotation has been suggested as a cause of failure of hemiarthroplasty of the proximal humerus. Placing a shoulder prosthesis in relationship to the bicipital groove might reproduce individual anatomy more reliably than using a standardized retrotorsion. The purpose of this study was to determine criteria for accurate adjustment of retrotorsion even when the proximal bicipital groove is destroyed, as is the case in fractures. The distance of the humeral head equatorial plane to the center of the bicipital groove was measured by high-resolution computed tomography at 4 levels (proximal and distal with 2 intermediate levels). The distal distance was considered to correspond to available references in fracture cases. The mean proximal distance was 8.0 mm (10th percentile, 6.2 mm; 90th percentile, 9.8 mm), and the mean distal distance was 8.5 mm (10th percentile, 7.1 mm; 90th percentile, 9.9 mm). As to the clinical relevance, there was no statistically significant difference between distances. For practical purposes in fracture indications, it is adequate to adjust the retrotorsion of the prosthetic component to the distal bicipital groove.

Treatment of tibial plateau fractures with small fragment internal fixation: a preliminary report.

OBJECTIVE: To evaluate the use of small fragment implants for fractures of the proximal tibia. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Seventeen patients with AO Classification Type B and C fractures of the proximal tibia. Two patients were lost to follow-up. INTERVENTION: After atraumatic dissection and open reduction, fracture stabilization was accomplished with the use of the AO/ASIF small T-plate (3.5-millimeter system). In two patients a medial uniplanar external fixator was applied as additional fixation. In six patients a cancellous autograft was performed. MAIN OUTCOME MEASUREMENTS: At an average follow-up of forty-two months (range, 24 to 75 months), all patients were evaluated radiographically and functionally. The incidence of local complications was specifically recorded. RESULTS: Postoperatively, the radiographs showed 86.7 percent anatomic or near anatomic reduction with respect to the articular joint surface. In three separate patients condylar widening, condylar narrowing or varus deformity was evident. In one patient, a minimal secondary displacement of less than two millimeters was observed before bony healing. All fractures healed within twelve weeks. At the latest follow-up, there were 53.3 percent excellent, 33.3 percent good, and 13.3 percent fair results. There were no infection or soft tissue complications. CONCLUSIONS: The use of small fragment implants combined with atraumatic soft tissue dissection potentially offers good results for the treatment of fractures of the proximal tibia. These initial results suggest that this technique may have the advantage of anatomic reduction while comparing favorably with less invasive methods regarding radiologic and functional outcome as well as incidence of complications.

The evolution of indirect reduction techniques for the treatment of fractures.

During the last decade, classic AO/ASIF techniques for internal fixation shifted from direct reduction and rigid fixation to biologic internal fixation using indirect reduction techniques. Biologic internal fixation is characterized by the preservation of bone and soft tissue vascularity and relative rather than absolute mechanical stability. Reduction is achieved by using soft tissue traction while obtaining axial and rotational alignment and the correct length. Stabilization is performed when possible by compression plating for load sharing or by bridge plating in comminuted fractures. Advancements of these techniques and the development of newer implants that minimize vascular damage have contributed to the development of biologic internal fixation. By using indirect reduction, by using longer plates to improve the mechanical leverage, and by applying fewer screws to avoid unnecessary damage to the bone, fracture union rates were high. There also was a decreased need for supplemental bone grafting. All of these factors provided stable fixation and allowed early motion.

The connective-tissue envelope in revascularisation of patellar tendon grafts.

Free patellar tendon grafts used for the intra-articular replacement of ruptured anterior cruciate ligaments (ACL) lack perfusion at the time of implantation. The central core of the graft undergoes a process of ischaemic necrosis which may result in failure. Early reperfusion of the graft may diminish the extent of this process. We assessed the role of peritendinous connective tissue in the revascularisation of the patellar tendon graft from the day of implantation up to 24 days in a murine model using intravital microscopy. The peritendinous connective-tissue envelope of the graft was either completely removed, partially removed or not stripped before implantation into dorsal skinfold chambers of recipient mice. Initial revascularisation of the grafts with preserved peritendinous connective tissues began after two days. The process was delayed by five to six times in completely stripped patellar tendons (p < 0.05). Only grafts with preserved connective tissues showed high viability whereas those which were completely stripped appeared to be subvital. The presence of peritendinous connective tissues accelerates the revascularisation of free patellar tendon grafts.

On the timing of soft-tissue reconstruction for open fractures of the lower leg.

The timing of soft-tissue reconstruction for severe open fractures of the lower leg is considered crucial to the later outcome, and yet pertinent publications are few. The purpose of this study was to add some based on evidence arguments for the choice of the most adequate timing in the management of these injuries. Twenty-nine consecutive open fractures of the tibia, including 24 grade 3B and 5 grade 3C fractures, were treated using a protocol of immediate debridement, early definitive skeletal stabilisation and early soft-tissue reconstruction. Fifteen lower legs were reconstructed after a mean delay of 4.4 days (range 1-9 days), while 14 lower legs were reconstructed immediately, i.e. as an emergency procedure on the day of admission. Both groups were comparable for sex, age, type of trauma, associated general injuries, type of fracture, associated arterial lesion, associated tendon rupture, type of soft-tissue reconstruction and duration of follow-up. All patients were reviewed at a mean follow-up of 47 months (range 15-89 months). In the delayed reconstruction group the time to full, unprotected weight-bearing (P = 0.0021), the time to definitive union (P = 0.0049), the number of reoperations (P = 0.0001) and the infection rate (P = 0.0374) were significantly higher. The data suggest that immediate reconstruction is, the general condition of the patient permitting, the timing of choice for soft-tissue coverage.

The medial malleolar network: a constant vascular base of the distally based saphenous neurocutaneous island flap.

Based on 30 fresh cadaver dissections a detailed anatomic study of the medial malleolar network is presented with particular attention to the anastomoses between the latter and the vascular axis that follows the saphenous nerve. The medial malleolar network is formed by the anterior medial malleolar artery, branches from the medial tarsal arteries, the posterior medial malleolar artery and branches from the medial plantar artery. A distinct anterior medial malleolar artery and posterior medial malleolar artery could be identified in 80 and 20%, respectively, as well as constant additional small branches arising from the anterior tibial or posterior tibial artery. A constant anastomosis was found between the arcade formed by the medial tarsal arteries and the medial plantar a. in 60%, and the medial branch of the medial plantar artery in 40%, respectively. This anastomosis always gave rise to branches to the medial malleolar network. In the perimalleolar area and with regard to the great saphenous v. a larger anterior and a smaller posterior branch of the saphenous nerve was found in 100 and 90%, respectively. In all dissections, for both branches of the saphenous nerve two to four small, but distinct anastomoses between the medial malleolar network and the perineural vascular axis were identified. These constant anastomoses represent a new and reliable vascular base for the distally-based saphenous neurocutaneous island flap. Thus, the pivotal point of the flap can be chosen in the area of the medial malleolus without respecting the most distal septocutaneous anastomosis between the perineural vascular axis and the posterior tibial artery. Additionally, an illustrative clinical case is presented.

[Missed compartment syndrome after anterior cruciate ligament-plasty following continuous peridural anesthesia]. / Verpasstes Kompartmentsyndrom nach vorderer Kreuzbandplastik infolge kontinuierlicher Periduralanästhesie.

In this article we report a case of an early postoperative compartment syndrome of the anterior tibial compartment with complete sensomotoric palsy of the peroneal nerve after arthroscopic-assisted replacement of the anterior cruciate ligament (ACL) of the knee. The tourniquet pressure was 360 mm Hg and operation time was 1.75 h. After the operation the leg was bandaged to avoid swelling of the leg and as antithrombotic prophylaxis. Analgesic therapy was by continuous epidural bupivacaine infusion. Increasing pain of the lower leg was suppressed by additional analgesia. Due to persistent pain despite regular analgesia, the patient was sent to a main hospital on the 3rd postoperative day, where an extremely painful and swollen anterior tibial compartment with intracompartmental pressure of over 100 mm Hg was found. The compartment was released immediately. Despite the appearance of severe muscle damage, no extensive débridement was done. At the second examination, at 48 h, there was minimal perfusion of the muscles without contraction and islands of ischemic necrosis. Clinically, there was complete palsy of the dorsiflexors of the foot. The case shows the danger of a compartment syndrome when tourniquet of the limb, arthroscopy and a firm bandage are combined. Continuous epidural analgesia masks the classic symptoms of compartment syndrome.

The deltoid extension lag sign for diagnosis and grading of axillary nerve palsy.

The deltoid extension lag sign has been developed to avoid the pitfalls confounding the diagnosis of an axillary nerve lesion. The physician elevates the arm into a position of near full extension. The patient is asked to attempt active maintenance of this position. If the deltoid is weak, the arm will drop. In five patients with traumatic axillary nerve palsy after anterior dislocation of the shoulder, the deltoid extension lag sign was used to evaluate the functional status of the deltoid muscle. The magnitude of the angular drop, or lag, of the arm was a precise indicator of the functional status and recovery of the deltoid. The sign proved to be objective and reproducible, allowing confident assessment of deltoid function and when repeated over time allowed precise follow-up of deltoid recovery.

[Indications and results of shoulder prosthetics in complex proximal humerus fractures]. / Indikation und Resultate der Schulterprothetik bei komplexen proximalen Humerusfrakturen.

Complex fractures of the proximal humerus are uncommon injuries and a therapeutic challenge to the orthopaedic surgeon. Successful treatment requires proper evaluation of the patient and analysis of standardized high-quality radiographs. The trauma series of radiographs (including true anteroposterior and lateral views in the scapular plane, and axillary view) is essential for accurate fracture assessment. Generally, joint-preserving reconstructive techniques are emphasized, aiming at restoration of the anatomy of the proximal humerus. In young individuals with excellent quality of the bone fragments, careful techniques of reduction and fixation, avoiding additional surgical devascularization, should be performed, even in case of possible impairment of the vascular supply to the humeral head. In elderly individuals with osteoporotic bone and limited compliance throughout aftercare, humeral head replacement may be indicated less restrictively. In the latter group hemiarthoplasty generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable.

The reversed-flow medio-distal fasciocutaneous island thigh flap: anatomic basis and clinical applications.

A new fasciocutaneous reversed-flow island flap of the thigh is presented which is independent of the presence of perfused blood vessels below the level of the knee joint-line. The pedicle, which is supplied by the proximal genicular anastomotic network, consists of the osteoarticular branch (OAB) and concomitant veins of the descending genicular artery. Based on cadaver dissections the OAB arose in 23/30 specimens (77%) together with the saphenous artery (SA). In 2/30 specimens (7%) the OAB originated directly from the superficial femoral artery and in 1/30 specimens (3%) the OAB was absent. The OAB gave off one to three cutaneous branches to the overlying skin in 26/30 specimens (87%). We were able to elevate a flap on the osteoarticular branch alone in 57%. Additional length could be added to the pedicle in 33% by including the most proximal part of the saphenous artery together with its first cutaneous branch. Thus, in 90% of the dissections a reversed-flow island flap could be raised which reached the proximal half of the leg, the knee and the most distal part of the thigh. We report our early clinical experience.

Decortication and plate osteosynthesis for nonunion of the clavicle.

Between 1968 and 1995, 37 patients with ununited fractures of the clavicle were treated by decortication and plate osteosynthesis. Thirty-two (86%) were failures of union of fractures of the middle third. Thirty-four (92%) patients had post-traumatic nonunion or delayed union. Sixteen (43%) patients had undergone primary operative treatment. Autogenous cancellous bone graft was used in 24 (65%) patients with atrophic nonunion. Nine tricortical, iliac crest, intercalary grafts were used for segmental bone loss equal to or greater than 15 mm. At the end of treatment, union had been achieved in 35 (95%) cases. At a mean follow-up of 8.6 years (range 13 months to 17 years), 32 (86%) patients had no symptoms and had a full range of motion of the shoulder. Decortication with plate osteosynthesis is a reliable, durable technique for the management of symptomatic, ununited fractures of the clavicle.

Transacromial approach to obtain fusion of unstable os acromiale.

The purpose of this study was to identify possible causes for the low union rate for surgically stabilized os acromiale. Between February 1990 and November 1995, fusion of an os acromiale was attempted in 15 shoulders in 12 patients at our institution. All patients were men. The mean age was 54 years (range 37 to 63 years). All shoulders had an os mesoacromiale considered too large for simple resection. An associated lesion of the rotator cuff ranging from partial-to full-thickness tear was present in all patients. Eleven had an unfused acromial epiphysis in both shoulders. Two different surgical approaches were used. Seven shoulders were approached through an anterior deltoid-off approach, thus potentially devascularizing the os acromiale. Eight shoulders were approached transacromially, preserving the deltoid origin and hence the terminal branches of the thoracoacromial artery. The technique of internal fixation (tension band wiring) was the same for both groups. The mean follow-up was 44 months (range 13 to 72 months). Union, as demonstrated by axial radiographic views, occurred in 3 out of 7 cases with a devascularized os acromiale and in 7 out of 8 shoulders with a perfused os acromiale (P = .017), respectively. Patients with a united os acromiale had a significantly better functional outcome as measured by the Constant score (P = .0169). In conclusion, aiming at a stable fusion of a sizable and hypermobile os acromiale is probably desirable because it enhances the overall functional result. Obtaining consolidation was possible when the vascularity of the acromial epiphysis was respected.

[Treatment concept in complex fractures of the head of the tibia]. / Behandlungskonzept bei komplexen Tibiakopffrakturen.

Complex tibial condylar fractures are intraarticular fractures with associated lesions of capsule and ligaments, menisci, soft tissue envelope and neurovascular structures. They are in general produced by a high-energy trauma and are usually part of a polytraumatized patient. The frequency for the associated lesions are up 50% for the collateral ligaments, and up to 40% for the cruciate ligaments and the menisci, respectively. The paper presents the crucial steps of clinical and radiological assessment and outlines a concept of treatment, documented by two illustrative cases.

Operative management of the stiff elbow: sequential arthrolysis based on a transhumeral approach.

Between December 1990 and September 1993, 26 consecutive patients (27 elbows) were treated for elbow contractures. We used a modified transhumeral approach supplemented by a limited lateral approach with or without a limited medial approach according to the correction gained after each step of the procedure. Eleven posttraumatic, 6 degenerative, and 10 miscellaneous contractures were evaluated. The mean follow-up was 30 months. Statistically significant improvement in the range of motion was obtained for all groups of patients; the mean flexion-extension arc of motion increased from 66 degrees to 100 degrees for the posttraumatic contractures, from 79 degrees to 102 degrees for the degenerative contractures, and from 85 degrees to 121 degrees for a miscellaneous group of contractures. Relief of pain was not an issue in the posttraumatic group; it was not significant for the degenerative group but was significant for the miscellaneous group. Flexion and extension force were maintained, and no joint was made unstable. Complications included three transient ulnar neuropathies and one tardy ulnar nerve palsy. The technique presented offers the advantage of virtually unlimited exposure of the joint in a stepwise manner, dictated by the intraoperative assessment of joint motion combined with preservation of the medial and lateral collateral ligament complexes and all relevant muscle insertions and origins. The concept is applicable to contractures of differing cause and can be adapted to the specific needs of the patient.