Osteochondral injuries. Clinical findings.

Osteochondral injuries are common, mainly affecting a young, active population. Failure to recognize these injuries can lead to long-term disability. A heightened awareness and understanding of the common mechanisms of injury will lead to early diagnosis and rapid recovery. This, along with improved treatment modalities, will keep any long-term disability to a minimum.

Contaminated anterior cruciate ligament grafts: the efficacy of 3 sterilization agents.

PURPOSE: A study was undertaken to determine the incidence of positive cultures resulting from an anterior cruciate ligament (ACL) specimen dropped on the operating room floor and the efficacy of sterilizing the specimen by soaking in 1 of 3 antimicrobial solutions: an antibiotic solution of neomycin and polymyxin B, 10% providone-iodine solution, and standard chlorhexidine gluconate solution. TYPE OF STUDY: Randomized trial. MATERIALS AND METHODS: Fifty ACL specimens removed from patients undergoing total knee arthroplasty were used as the test group. The specimens were longitudinally sectioned into 4 equal pieces. The 4 pieces were dropped on the floor and left for a period of 15 seconds. Cultures were taken from each specimen after immersion in 1 of the 3 sterilization solutions for a period of 90 seconds. One of the 4 specimens was cultured without being exposed to any solution, thereby establishing these specimens as the control group. Cultures of a floor swab were taken at the same time and place that the ACL was dropped. RESULTS: The floor swab cultures were positive in 48 of the 50 specimens (96%). The ACL control group (untreated dropped grafts) had 29 of 50 specimens positive (58%). The grafts soaked in antibiotic solution had 3 of 50 specimens positive (6%). The grafts soaked in providone-iodine solution had 12 of 50 specimens positive (24%). The grafts soaked in chlorhexidine gluconate solution had 1 of 50 specimens positive (in broth only) (2%). CONCLUSION: This study shows that significant contamination occurs when dropping specimens on the floor, as 58% of the dropped grafts had positive cultures. Of the 3 sterilization techniques used, chlorhexidine gluconate seems to be the most efficient with only a single broth culture (2%) found to be positive. The antibiotic solution was second best (6%), although there is no statistically significant difference between these 2 groups. The 10% providone-iodine solution under these test conditions was the least effective of all the 3 sterilization agents with 24% cultures positive after immersion.

Osteonecrosis of the knee after arthroscopic surgery for meniscal tears and chondral lesions.

PURPOSE: Avascular necrosis of the knee following arthroscopic surgery has been described. The purpose of this article is to report a large series of patients who developed avascular necrosis after arthroscopy of the knee in an effort to delineate casual factors and results of treatment. TYPE OF STUDY: Case series. METHODS AND MATERIALS: The charts, radiographs, and magnetic resonance imaging (MRI) scans of patients who developed osteonecrosis (ON) of the knee after routine arthroscopic surgery were reviewed. Only those patients with no evidence of ON on preoperative MRI performed 6 weeks or longer after symptom onset and who postoperatively developed ON confirmed by repeat MRI and/or by pathological testing (specimens obtained at subsequent total knee arthroplasty) were included in the study. Seven patients with average age of 60 years (range, 41 to 79 years) met these inclusion criteria. RESULTS: The lesions noted at arthroscopy included 4 medial meniscus tears, 3 lateral meniscal tears, 6 chondromalacia of the medial femoral condyle, 2 chondromalacia of the medial tibial plateau, 1 chondromalacia of the lateral femoral condyle, 1 chondromalacia of the lateral tibial plateau, and 2 chondromalacia of the patella. The location of postarthroscopy ON correlated geographically with pre-existing pathology. All 7 patients had meniscal and/or chondral lesions addressed surgically in the compartment that subsequently developed ON. Six of the 7 patients had an adjacent ipsilateral meniscus tear treated with partial meniscectomy (4 medial, 2 lateral). In addition, of the 4 patients who developed ON of the medial femoral condyle, all had overlying chondromalacia, 3 of whom were treated with arthroscopic chondroplasty. Of the 2 patients with lateral meniscal tears, 1 developed ON of the lateral femoral condyle and the other developed ON of the lateral tibial plateau. Three patients went on to require total knee arthroplasty, and 2 high tibial osteotomy. One patient's ON resolved and another patient was lost to follow-up. CONCLUSION: ON should be considered in patients who have worsening symptoms after arthroscopy of the knee. These findings suggest a possible relationship between arthroscopic treatment of chondral and meniscal lesions and later appearance of ON in some patients. The role of arthroscopy in the development of ON needs to be further studied. Those at risk are elderly patients with chondral and meniscus lesions.

The incidence of injury in Texas high school basketball. A prospective study among male and female athletes.

Recent publications have reported differences in the incidence, rate, risk, and type of sports injury among men and women. We undertook a prospective study to determine the incidence of injury among high school basketball players and to examine the differences in injury type, incidence, rate, and risk between male and female athletes. During a single basketball season, an injury survey of girls' varsity teams at 100 class 4A and 5A high schools in Texas was conducted. These data were previously reported. We surveyed the same 100 high schools during a subsequent season to gather injury data from the boys' varsity teams. The athletic trainer collected data on each reportable injury and reported the data weekly to the University Interscholastic League. A reportable injury was defined as one that occurred during a practice or a game, resulted in missed practice or game time, required physician consultation, or involved the head or the face. The boys' and girls' data were compared and statistically analyzed. The rate of injury was 0.56 among the boys and 0.49 among the girls. The risk of injury per hour of exposure was not significantly different between the two groups. In both groups, the most common injuries were sprains, and the most commonly injured area was the ankle, followed by the knee. Female athletes had a significantly higher rate of knee injuries including a 3.79 times greater risk of anterior cruciate ligament injuries. For both sexes, the risk of injury during a game was significantly higher than during practice.

Incidence of injury in Texas girls' high school basketball.

We studied the incidence of injury in girl's varsity basketball to characterize injury demographics in high school athletics. We defined a reportable injury as one that occurred during organized practice or competition, resulted in either missed practice or game time, required physician consultation, or involved the head or face. We prospectively evaluated the athletes on team rosters during the 1993 to 1994 season from 100 randomly selected Class 4A and 5A Texas public high schools that employed full-time certified athletic trainers. The 890 student athletes from 80 schools ranged in age from 14 to 18 years. Four hundred thirty-six injuries were reported for a rate of 0.49 per athlete per season. Injury risk, calculated on the basis of exposure time, was 0.4% per hour per athlete. Although game time accounted for only 12.5% of exposure time, it represented one half of the total injuries. Sprains and strains (56%) were the most common injuries, followed by contusions (15%) and dental injuries (14%). Injuries to the ankle (31%) and knee (19%) were by far the most common. There were 34 severe injuries defined as requiring surgery or hospitalization, for a rate of 0.038 per athlete per season. Knee injuries were by far the most likely to require surgeries, and ACL injuries accounted for 69% of the severe knee injuries.

Meniscal repair. An experimental study in the goat.

To evaluate the healing potential of the meniscus, we created a longitudinal medial meniscal tear in both knees of 24 adult goats (48 knees). In all goats, the meniscus was repaired in one knee and left unrepaired in the other. The goats were placed into one of three groups based on the location of the tear and the status of the anterior cruciate ligament. At 6 months' followup, an arthrogram was obtained and the menisci were examined. In knees with an intact anterior cruciate ligament, tears in the peripheral 20% to 25% of the meniscus healed in six of seven repaired menisci, but in only one of seven of the unrepaired menisci. Tears in the peripheral 40% to 50% healed in only one of the eight repaired menisci and in none of the unrepaired menisci. When the anterior cruciate ligament was incised, tears in the peripheral 20% to 25% of the meniscus healed in only 1 of 8 repaired menisci and in none of the unrepaired menisci; the rest developed into complex tears. Arthrography was 92% accurate in predicting the status of meniscal repair. This study supports current clinical practices in meniscal repair and emphasizes the importance of tear location and knee stability in successful meniscal repair.

The diagnosis and treatment of medial subluxation of the patella after lateral retinacular release.

Five patients with medial subluxation of the patella occurring after isolated lateral retinacular release were treated between July 1985 and July 1989. The diagnosis was made by clinical examination. The patients complained of pain, swelling, and giving way after the lateral release. All five patients had increased medial passive patellar mobility, a positive gravity subluxation test, and a positive medial apprehension test. All patients failed conservative treatment. The patients were treated by reconstruction of the lateral retinaculum using sensory epidural anesthesia. At an average followup of 3.3 years, four of the five patients had no symptoms of instability and the medial patellar mobility and gravity subluxation tests were negative. There were three excellent and two good results using the grading system of Merchant and Mercer.

The incomplete bicruciate knee injury. A report of two cases.

Two patients suffered similar knee injuries due to valgus stress and hyperextension. Examination under anesthesia and arthroscopic evaluation revealed a previously unreported ligament injury pattern. Both patients had a complete tear of the anterior cruciate ligament and a partial tear of the posterior cruciate ligament; neither was noted to have a dislocation. The descriptive term identifying this injury pattern is "incomplete bicruciate knee injury." The purpose of this report is to identify this knee-injury complex, which appears to be part of the sequence that leads to complete tears of both cruciate ligaments--the classic knee dislocation.

Incidence of injury in Texas high school football.

This study was undertaken to determine the incidence of injury in high school football based on evaluation of 100 high schools in the State of Texas during a single football season (1989). Certified athletic trainers were the initial medical professionals providing on-site diagnosis and treatment of all injuries. An injury was defined as: 1) an incident causing an athlete to miss all or part of a single practice or game; 2) any incident treated by a physician; and 3) all head injuries reported to the athletic trainer. Data were collected that allowed calculation of the time of exposure to injury per athlete in the sample. There was 75.5% participation in the study by the certified athletic trainers in the 100 schools. A total of 4399 athletes in varsity football programs participated in the study. There were 2228 injuries, as defined in the study, during the period of study, giving an incidence of injury of 0.506 injury per athlete per year. Severe injuries--those requiring hospitalization--were found in 137 cases, for an incidence rate of 0.031 injury per athlete per year. The incidence of reportable defined injury was calculated to be 0.003 injury per hour of exposure per student athlete. The knee was found to be the most commonly injured anatomic site; the ankle ranked second.

Research note: the in vitro responses of vaginal tissue and chicken spermatozoa to glycerol.

The fertilizing ability of glycerolized spermatozoa is apparently lost due to reactions between glycerol, spermatozoa, and vaginal tissue. Two experiments were conducted to determine the feasibility of using in vitro cultures to quantitatively assess these reactions. In the first experiment, vaginal slices alone, unglycerolized semen, and vaginal slices plus semen, all in a phosphate-buffered saline were studied. The media were separated into 14 fractions using HPLC and the absorbance of each fraction was measured at 0 and 1 h of incubation. In a second experiment the changes in absorbance of these fractions were examined for unglycerolized and glycerolized semen in vaginal cultures. When unglycerolized semen was added to the vaginal cultures, Fraction 55 appeared in significantly greater absorbance than in vaginal tissue or semen alone. The opposite occurred for Fraction 57, which decreased in absorbance after 1 h of incubation in semen-vaginal culture. Fraction 57 was increased in absorbance in the presence of glycerol in the semen-vaginal culture. Glycerol appears to block the appearance of Fraction 55 in the normal semen-vaginal reaction. This reaction may be responsible for the deleterious effects of glycerol on spermatozoal survival in vivo.

Anterior cruciate ligament reconstruction using bone-patellar tendon-bone allografts. A biological and biomechanical evaluation in goats.

Twenty-eight goats underwent ACL reconstruction with freeze-dried bone-patellar tendon-bone allografts in one knee, the opposite knee serving as a control. One group of 16 knees was evaluated, in groups of four, at 6, 12, 26, and 52 weeks by histologic and vascular injection techniques. The other group of 12 knees was evaluated in two groups of six at 26 and 52 weeks by morphological and biomechanical techniques of analysis. Within the first 12 weeks these allografts were revascularized; in the first 26 weeks they had matured to resemble normal connective tissue. Graft stiffness was 29% of the control value and maximum force to failure was 43% of the control value. The results of this study indicated that freeze-dried bone-patellar tendon-bone allografts are biomechanically and biologically similar to patellar tendon autografts.

The history and classification of knee braces.

There has been a great deal of concern within the orthopedic community regarding the lack of objective data available on the multitude of knee braces flooding the marketplace. This article hopes to fill that void by presenting an overview of the history and classification of knee braces.

Effects of feeding lasalocid on performance of broilers in moderate and hot temperature regimens.

Three trials were conducted in environmental chambers to study the effects of feeding lasalocid on broiler performance. Birds were randomly assigned at 31 or 35 days of age to one of four treatment groups: hot cyclic (26.7 to 37.8 C and 90 to 40% RH) with basal diet; hot cyclic with lasalocid diet (88 mg/kg); moderate constant (21 C and 50% RH) with basal diet; or moderate constant with lasalocid diet. All birds were killed and processed 2 wk after the start of each trial. Percentage of carcass yield and fat pad weight were determined. In the moderate temperature regimen, lasalocid feeding caused a depression in the 2nd wk gain (469 versus 486 g) but not in the final 2-wk gain. In the hot temperature regimen, birds fed lasalocid gained significantly more weight in the 2nd wk than those fed the basal diet (341 g versus 325 g) and had a significantly better feed conversion in the 2nd wk (2.04 versus 2.61) and overall (2.07 versus 2.32) than those fed the basal diet.

Failed partial meniscectomy.

Both patients and doctors have come to expect a high rate of success from arthroscopic partial meniscectomy. Failure of this procedure may result from a number of causes, most of which can be detected preoperatively. This article elucidates these potential pitfalls so that the patient can be offered better preoperative counseling.

Reflex sympathetic dystrophy of the knee. Treatment using continuous epidural anesthesia.

We retrospectively reviewed the cases of fourteen patients who had reflex sympathetic dystrophy of the knee. All fourteen were hospitalized, and epidural block anesthesia was instituted with an indwelling catheter for an average of four days, during which continuous passive motion, manipulation (as necessary), stimulation of muscles, and alternating hot and cold soaks were used. The average length of follow-up was thirty-two months. Eleven patients had complete resolution of the symptoms, two had sufficient intermittent aching with changes in the weather to need medication, and one had no relief. The diagnosis was confirmed if the symptoms were relieved by a lumbar sympathetic block. Pain that was out of proportion to the severity of the injury was the most consistent finding, being present in all fourteen patients. However, variation in clinical severity is characteristic of the syndrome. Eleven of the fourteen patients had had a previous patellar operation. After the onset of the symptoms, nine patients had two or more arthroscopic examinations, without notable findings. All fourteen patients had had extensive physical therapy and medical treatment before the epidural block was performed.

Fractures of the base of the fifth metatarsal distal to the tuberosity: a review.

Fractures of the proximal part of the fifth metatarsal can be separated into two types: those involving the tuberosity, and those involving the proximal part of the diaphysis distal to the tuberosity. Recently it has been recognized that the latter group, Jones' fractures, may be difficult to treat. Although reports in the literature have indicated the potential difficulties in the treatment of Jones' fractures, prevailing guidelines for their management are ambiguous. Apparently the varied clinical and roentgenographic manifestations of these fractures have not been correlated with their response to treatment. In this paper we describe a classification of these fractures and a plan of treatment based on clinical and roentgenographic criteria that were developed to define acute fractures, delayed unions, and nonunions. The treatment of choice for acute fractures is immobilization of the limb in a toe to knee cast with nonweight-bearing. Fractures with delayed union may eventually heal if they are treated conservatively, but an active athlete with delayed union or an established nonunion will benefit from operative intervention. The procedures of choice are medullary curettage and bone grafting, and closed axial intramedullary screw fixation using a 4.0-mm ASIF malleolar screw.

Chronic non-hematogenous osteomyelitis treated with adjuvant hyperbaric oxygen.

Between 1979 and 1982, thirty-eight patients with chronic non-hematogenous osteomyelitis were treated by local débridements of the wound, prolonged parenteral administration of antibiotics, and an average of forty-eight once-a-day treatments with hyperbaric oxygen. Of these thirty-eight patients, thirty-four remained free of clinical signs of osteomyelitis for an average of thirty-four months (range, twenty-four to fifty-nine months) after this regimen of treatment. Only four of the thirty-eight patients had been free of clinical signs of osteomyelitis for as long as three months during the two years preceding this treatment. Three of the four failures of treatment were evident within one month after treatment. This method of treatment appears to prolong the infection-free interval of patients with chronic non-hematogenous osteomyelitis.

Zone approach to knee arthroscopy.

The zone approach to knee arthroscopy divides the knee into ten anatomic zones. This article presents the zone classifications and describes the combination of portals for the arthroscope, the probe, and the operating instruments. The particular leg position which is thought to allow the best visualization of each zone is also described. Alternate portals are necessary in certain situations, as in knees with tight ligamentous structures. This list of standard and alternate portals is not meant to be all-inclusive, but we do urge that all ten zones are examined during arthroscopy. The objectives of this article are to describe a method of arthroscopic examination that is both systematic and comprehensive, and to develop an arthroscopic nomenclature that allows easy localization and reporting of pathology in the knee joint.