Proximal tibial osteotomy in patients who are fifty years old or less. A long-term follow-up study.

Proximal tibial valgus osteotomy was performed for unicompartmental osteoarthritis in forty-five patients (fifty-one knees). The average age of the patients was forty-one years (range, twenty-three to fifty years), and the average length of follow-up was ten years. At follow-up, 70 per cent (thirty-six knees) were rated as good or excellent and 30 per cent (fifteen knees) were rated as fair or poor. There was no clear correlation between the quality of the result and the radiographic evidence of the severity of the arthritis preoperatively, the age of the patient at osteotomy, or the length of follow-up. There was a correlation between an improved result and an increased angle of correction after osteotomy, but the values were not statistically significant. The most important factor influencing the quality of results was the over-all level of disease in the knee as reflected in the preoperative knee score. Deficiency of the anterior cruciate ligament at the time of the osteotomy did not prevent a good result. We believe that proximal tibial osteotomy for unicompartmental arthritis of the knee is a good and effective procedure for patients who are less than fifty years old and who have an active life-style, and that lasting results can be achieved if the procedure is done early in the course of the disease.

Considerations in total knee arthroplasty following previous knee fusion.

Two patients who were dissatisfied with the functional results of knee fusion had conversion to total knee arthroplasty at one and 16 years following previously solid fusion. Both patients were over 65 years of age. Unconstrained prosthetic components were used and no special soft tissue stabilizing procedures were needed. At follow-up examinations, five and one-half and three years postoperatively, the results have been gratifying with good stability and adequate range of motion from 0 degrees to 90 degrees of flexion. Both patients were able to walk and climb stairs without support. The patients claimed that quality of function was significantly improved. Whenever possible, fusion of the knee in young people should be done so that this option remains open in later life. Arthrodesis is advised in young patients to allow for possibility of revision to total knee arthroplasty at a later date as technology improves.

Stress fracture of the ribs in female rowers.

Stress fractures of the lower ribs related to sports are rare. Fractures of the ribs related to rowing sports have not been reported. We have documented seven cases of stress fractures of the lower ribs in female athletes; four were elite rowers and three were engaged in tennis, golf, and gymnastics. Each athlete was initially seen and treated elsewhere for muscular strain. All athletes presented with pain in the posterolateral thorax in and around the scapula. The time from onset of symptoms to diagnosis ranged from 2 to 6 months. Bone scans were used to document the fractures when roentgenograms were equivocal. Each athlete responded to a 4 to 8 week period of rest or training modification. Biomechanical analysis of the forces across the ribs demonstrates that these fractures tend to occur along the posterolateral segment where the bending stresses on the rib are greatest. The predominant muscle forces are generated by the forced couple of scapular retraction and protraction acting through the serratus anterior. We postulate that inadequate strength and resistance training background in women is the cause for the apparent increased susceptibility of women to these skeletal injuries.

Treatment selection in acute anterior cruciate ligament tears.

Traumatic hemarthrosis associated with rupture of the anterior cruciate ligament is one of the most common ligament injuries encountered in sports medicine today. Its management is difficult because of the combination of presenting pathology as well as the multitude of patient profiles encountered. Crucial to the decision on proper management of a particular patient is the accumulation of data concerning the patient's social and sporting life as well as a detailed physical examination. When doubt exists, the physician can use other tests, including arthrograms, examination under anesthesia, or arthroscopy, to confirm and expand his diagnosis. Generally, the patient will be easily categorized into one of three areas: those who require surgery and reconstruction, those who do not, and those whom a decision is not clear. In the treatment of rotatory instability of the knee, no single approach has proved to be a panacea. The multiple procedures available attest to the complexity of the situation. It is not easily decided who will do well with conservative treatment and who will not, although data show that many individuals with mild or moderate instability can be treated effectively this way. The patient must be involved in the decision process, although it is clearly the physician who brings his bias to bear. The key factor in the successful management of the knee with rotatory instability is the patient's individual ability and willingness to modify his activities and select those sporting events compatible with his level of instability and general coordination. Rehabilitation is important for optimal results in both the conservatively and operatively treated groups and involves the four principles of (1) protection during the healing phase, (2) prevention of reinjury, (3) achievement of previous performance levels, and (4) postponement of late degenerative changes. The role of the physician is to guide and support the patient in learning to accept his knee disability. The best medical management and advice are ever-changing. Future technologic breakthroughs may provide optimal solutions for knees with rotatory instability and may create surgical and rehabilitative techniques that will prove desirable to those patients who presently are unwilling or unsuited to take the risk of major surgical reconstruction and the long rehabilitative process associated with it.

The nonoperative treatment of grade I and II medial collateral ligament injuries to the knee.

A prospective investigation covering 8 years (1971 to 1978) at a major university was undertaken involving the nonoperative management of medial collateral ligament injuries to the knee. Rigid diagnostic criteria were used for each injury prior to inclusion in a program of functional rehabilitation without cast immobilization. Eighty-nine fresh ligamentous injuries were reviewed. Thirty-eight knees required surgery. The remaining 51 knees were classified as isolated Grade I or Grade II injuries. Forty-two (80%) successfully completed the program of rehabilitation. Nine (20%) were considered failures. These were attributed to inadequate diagnoses during the early period of the study. Average time required for the athletes to return to full competition was 21 days (range of 9 to 32 days.)