Arthroscopic treatment of anterior cruciate ligament avulsion.

A new technique is described for arthroscopic reduction and internal fixation (ARIF) of avulsion fractures involving the insertion of the anterior cruciate ligament (ACL). Conventional methods of treatment of ACL avulsion in adults may lead to suboptimal results owing to stiffness from either prolonged immobilization or the morbidity of arthrotomy. Contemporary techniques of arthroscopic reduction and percutaneous pinning do not achieve rigid fixation and thus still require cast immobilization. The placement of cannulated screws through the anteromedial arthroscopic portal provides rigid fixation while avoiding arthrotomy, allowing early mobilization and return to activity. The possibility of interstitial damage to the ACL and implications regarding tensioning of the ligament are considered A typical case illustrates ARIF of ACL avulsion. The technique minimizes morbidity and optimizes function.

Biceps tendon tenodesis for posterolateral instability of the knee. An in vitro study.

The effects of biceps tendon tenodesis on internal-external and varus-valgus laxity were measured using fresh-frozen cadaveric specimens that had undergone sequential sectioning of the posterolateral structures and of the fibular collateral ligament. Tenodesis (using 89 N graft tension and a fixation point located 1 cm anterior to the fibular collateral ligament's insertion on the femur) was effective in restoring external rotation and varus laxity; the procedure actually overconstrained external tibial rotation at all flexion positions and varus angulation at 60 degrees and 90 degrees of flexion. Internal rotation and valgus laxity were unaffected by the tenodesis procedure. The anterior fixation point was more effective in reducing laxity than a fixation point located 1 cm proximal to the fibular collateral ligament insertion. Tenodesis using the proximal fixation point, which was nonisometric, did not restore external rotation and varus laxities to intact values at 60 degrees and 90 degrees of knee flexion. Graft tension (45 or 89 N) had no measurable effect on the results of the tenodesis. This study has demonstrated that the biceps tenodesis procedure is effective for reducing static laxity in the knee with posterolateral instability.

Biceps tendon and superior labral injuries.

Twenty-two patients sustained injury to the biceps tendon, rotator cuff interval, or superior labrum. Seven patients with "interval lesions" underwent biceps tenodesis, one biceps repair, and three subscapularis repairs. All were satisfied, although one tenodesis failed with distal biceps retraction. Key arthroscopic findings included biceps or subscapularis fraying. Thirteen patients with "S.L.A.P. (superior labrum anterior to posterior) lesions" underwent labral debridement. All but one obtained pain relief. Eight cadaveric shoulders exhibited extreme anatomic variability of the bicipital origin/superior labral attachment. Biomechanical study showed anterior-superior and posterior-superior labral strain with simulated biceps contraction to be greatest in shoulder abduction (p < 0.01). Biceps tendon strain was greatest in shoulder adduction (p < 0.05). A continuum of injuries to the biceps tendon exist, from the rotator cuff interval to the labral attachment. Key arthroscopic findings may assist in the difficult diagnosis of interval lesions. Individual anatomy and mechanism of injury may determine the site of the lesion.

Resection arthroplasty of the hip.

The results of forty-eight resection arthroplasties (Girdlestone procedures) in forty-three patients were analyzed. The indications were sepsis after a total hip replacement (thirty-three procedures), aseptic loosening of a total hip replacement (ten procedures), and primary septic arthritis (five procedures). The resection arthroplasty effectively eradicated the sepsis in all but three patients, who had a recurrence. Pain was alleviated in nearly all of the patients, but the ability to walk and the level of activity improved only slightly. Shortening of the limb ranged from three to eleven centimeters, and all patients used a support for walking. The six patients who had a bilateral procedure were able to walk using double supports. With regard to relief of pain, walking, and function, the results were significantly poorer in the women, particularly the older ones. The results were also significantly inferior in the patients who had had sepsis after a total hip replacement. Generally, walking, function, and the level of activity were better when much of the proximal end of the femur had been retained. Resection arthroplasty should spare as much of the proximal end of the femur as possible if a future replacement of the hip is contemplated.

The effects of dexamethasone on periarticular swelling and joint stiffness following fracture in a rabbit hindlimb model.

An established rabbit hindlimb model was used to determine the effects of systemic steroid administration on posttraumatic limb swelling and joint stiffness. Dexamethasone acetate was administered intramuscularly to the test rabbits in one of four doses two hours following fracture as well as one and two weeks later. Dexamethasone did not produce a significant decrease in swelling but did produce a statistically significant dose-dependent decrease in ankle stiffness compared to controls. Tibia torsional strength to failure was not adversely affected.

Bilateral hip and knee arthroplasty.

Twenty-six severely deformed patients with prosthetic arthroplasty of both hips and both knees because of rheumatoid arthritis (16), juvenile rheumatoid arthritis (6), ankylosing spondylitis (2), osteoarthritis (1), and inflammatory arthritis, cause unknown (1), were followed for a mean of 6.8 years. Severe pain was the primary indication for surgery, and consistent and substantial pain relief was achieved. Most patients also had limited ambulatory and functional improvement. Computer analysis showed that this improvement was related only to preoperative walking and function and a combined hip and knee flexion of at least 190 degrees. All other parameters had no correlation with walking and function improvement. Of the 104 arthroplasties (52 hips and 52 knees), six implants (4 hips and 2 knees) in two patients failed and another seven implants (2 hips and 5 knees) in five patients were revised. Of the remaining 91 implants, 89 were clinically stable, and only two hip implants in two patients appeared destined for revision. However, when radiographic review was included, nine acetabular components, three THA femoral components, and five tibial components in 12 patients had some evidence of impending aseptic loosening, despite low patient activity levels.