Arthroscopic subacromial decompression: outcome comparison between outpatient and hospitalized patients with 2- to 5-year follow-up.

BACKGROUND AND AIMS: The purpose of this study was to evaluate the mid-term result of the arthroscopic subacromial decompression after failed conservative treatment of shoulder pain caused by subacromial impingement, when the patients were treated as an outpatient way or by staying overnight in hospital after surgery (hospitalized patients). Our hypothesis was that the results would be equal in both groups. MATERIAL AND METHODS: Arthroscopic subacromial decompression was performed in 80 consecutive patients, of which 40 patients were treated as an outpatient way (Outpatient Group), and 40 patients as a hospitalized way (Hospitalized Group). A prospective, comparative 2- to 5-year follow-up study including clinical examination, radiographic evaluation, isometric elevation strength measurements, as well as the University of California, Los Angeles (UCLA) and Constant shoulder scores was performed in 74 patients (93%). RESULTS: Preoperatively, the mean UCLA score was 19 (SD 3) in the Outpatient Group, and 19 (SD 3) in the Hospitalized Group. Respectively, the mean Constant scores were 62 (SD 10) and 60 (SD 11). At the follow-up, the mean UCLA score was 32 (SD 4) in the Outpatient Group, and 32 (SD 3) in the Hospitalized Group, which both indicated good clinical outcome. Respectively, the mean Constant scores were 95 (SD 7) and 92 (SD 11), which both indicated excellent clinical outcome. At the follow-up, the UCLA and the Constant shoulder scores were significantly bet-ter than preoperatively in both groups (p < 0.01, p < 0.01), although no differences were found between the groups.The duration of the sick leaves and ability to return to work were similar in both groups. Also, the isometric elevation strengths of the operated shoulders were equally good in both groups. CONCLUSIONS: According to this study, the results of arthroscopic subacromial decompression were equally good whether the patient was treated as an outpatient way or by staying over-night in hospital after surgery. The results were significantly better at follow-up than preoperatively in both groups. Key words: Shoulder pain; subacromial impingement; arthroscopic subacromial decompression; outpatient unit; hospitalized patient; clinical result.

Arthroscopic anterior cruciate ligament reconstruction using a hamstring graft with interference screw fixation.

BACKGROUND AND AIMS: This study assessed the clinical and radiographic results 3 to 8 years after an arthroscopic ACL reconstruction using a hamstring graft with interference screw fixation on femoral and tibial sites. MATERIAL AND METHODS: Seventy-six of 100 patients, who underwent an arthroscopic ACL reconstruction, could be re-examined with a mean follow-up of 5 years. RESULTS: The mean Tegner activity score was 4 (scale: 0 to 10) before surgery, and 5 at the follow-up. Fifty-four patients (78%) achieved a satisfactory result in the IKDC rating. The mean Lysholm score was 85 (scale: 0 to 100), the score being better in patients without meniscal resection than those with (P = 0.04). The mean side-to-side difference in anterior-posterior knee laxity was 1.8 mm, and 62 patients (90%) had good stability. Sixty-four patients (93%) had normal range of motion of the knee. Twelve patients (46%) with meniscal resection had osteoarthritic changes, compared with only 8 of those (20%) without meniscal resection (P = 0.03). CONCLUSIONS: This medium-term follow-up study showed that good stability and function and normal range of motion of the knee can be achieved in majority of the patients who have undergone an ACL reconstruction with a hamstring graft and interference screw fixation.

Muscle strength evaluations after ACL reconstruction.

The quadriceps and hamstring muscle strengths of 16 patients operated using a bone-patellar tendon-bone (BTB) autograft and 32 patients operated using a quadruple hamstring autograft for an arthroscopic anterior cruciate ligament (ACL) reconstruction were analyzed 4- to 7-years postoperatively. Standardized isokinetic testing, a clinical evaluation and instrumented assessment of knee laxity were done. The findings showed no significant strength deficits between the patients in the BTB and Hamstring groups and the deficits were, in general, small. The quadriceps and hamstring muscle strengths were better in patients with a longer than shorter follow-up and stable knees had less knee flexion torque deficit than unstable knees. Strength deficit was associated with lower Lysholm knee scores. The findings of this study showed that the muscle strengths of the operated limb had a positive association with the functional outcome of the knee in the long-term and support the use of active rehabilitation after ACL reconstruction.

A novel reconstruction technique for chronic lateral ankle instability: comparison to primary repair.

Twenty patients with lateral ankle instability were treated by a novel anatomical reconstruction technique (group A) and the results compared with 20 patients (group B) who, during the same period of time, underwent primary repair of ruptured lateral ligaments of the ankle. We reviewed 15 patients from group A and 17 patients from group B at a mean follow-up of between 2 and 4 years. The mean functional scores were good in both groups without significant difference, and there was no difference in the mean anterior talar translation between the two groups. We therefore conclude that chronic lateral instability of the ankle may be successfully treated, even in the presence of severely damaged, attenuated or absent ligament tissue.

Simple measurements in assessing muscle performance after an ACL reconstruction.

The purpose of this study was to evaluate the validity of the simple measurements of the muscle performance of the lower extremity, one legged hop testing for distance and the measurement of the circumference of the thigh 15 cm proximal to the joint line, by comparing them to the isokinetic strength testing 5 to 9 years after an ACL reconstruction with a bone-patellar tendon-bone (BTB) autograft. The measurements were performed on 86 patients on average 7 years after the surgery. The clinical evaluation was performed using the standard knee ligament evaluation form of the International Knee Documentation Committee (IKDC) and the Lysholm and the Marshall knee scores. At seven years, the isokinetic mean strength deficit of knee extension at the 60 degrees per second was 10 % in the operated limb as compared to the contralateral limb (NS). In the knee flexion, the differences were even smaller and statistically not significant either. The strength deficit of the knee extension at all knee angle velocities (p < 0.005), and flexion at 60 degrees per second (p < 0.05), correlated to the one legged hop testing, so that the patients with the greatest strength deficit also had the worst outcome in the one legged hop test. Also, the correlation between thigh atrophy and the deficit in the isokinetic strength test was significant in knee extension at all knee angle velocities (p < 0.001), and in knee flexion at 180 degrees per second (p < 0.005). In the final evaluation of the IKDC, 21 patients were rated as "normal", 51 as "nearly normal", 13 as "abnormal", and one as "severely abnormal". The mean of the Lysholm score was 83, classified as good, and that of Marshall score 43, classified as good. In conclusion, the one legged hop testing, as a functional muscle strength testing after an anterior cruciate ligament reconstruction, seems to correlate well with the isokinetic strength testing of the knee, especially in the knee extension. Because the hop testing can be easily performed and without extra equipment, we recommend its use for the evaluation of the functional muscle performance after an anterior cruciate ligament reconstruction. The measurement of the thigh atrophy is also easy to perform, and should be used beside the one legged hop testing, especially if the isokinetic strength testing is not available.

Graft placement after the anterior cruciate ligament reconstruction: a new method to evaluate the femoral and tibial placements of the graft.

In order to evaluate graft placement of the anterior cruciate ligament (ACL) reconstruction and its relationship to the clinical outcome of the patient, 100 patients were examined 7 years after an ACL reconstruction. Clinical assessment was performed using the standard knee ligament evaluation form of the International Knee Documentation Committee (IKDC), and the Lysholm and the Marshall knee scores. We developed a new evaluation method of graft placement after an ACL reconstruction, 'the sum score of the graft placement', which takes into account both the femoral and the tibial positions of the graft simultaneously, and our study showed that 'the sum score of the graft placement' has an association to clinical outcome of patients and that it can better explain the long-term osteoarthritic changes at the injured knee than the separate measurements of the femoral and tibial tunnel placements.

Anterior cruciate ligament reconstruction in patients with or without accompanying injuries: A re-examination of subjects 5 to 9 years after reconstruction.

PURPOSE: The purpose of this study was to compare the clinical and radiologic results of an anterior cruciate ligament (ACL) reconstruction in patients with an isolated ACL tear and patients with an ACL tear and accompanying injuries. TYPE OF STUDY: A retrospective investigation. METHODS: Seventy-two patients who did not have previous knee surgery or surgery of the contralateral knee were re-examined 5 to 9 years after the primary ACL reconstruction. The clinical assessment was made using the International Knee Documentation Committee (IKDC) evaluation system, and the Lysholm and the Marshall knee scores. Also, radiographic evaluation and isokinetic strength testing were performed. There were 34 patients (25 men and 9 women) with an isolated ACL tear (group A), and 38 patients (23 men and 15 women) with an ACL tear and accompanying injuries (group B). The mean age was 29 years (SD 9; range, 15 to 49 years) in group A, and 34 years (SD 12; range, 15 to 61 years) in group B. Bone-patellar tendon-bone autograft with mini-arthrotomy technique and screw fixation was used in all patients. Postoperative rehabilitation was also similar in both groups. In group B, 10 medial and 12 lateral (partial or subtotal) arthroscopic meniscectomies were performed at the same time as the ACL reconstruction. Also, 18 of the 19 medial collateral ligament ruptures, the 2 lateral collateral ligament ruptures, and the 1 posterior cruciate ligament rupture were treated surgically at this operation. RESULTS: Subjectively (overall assessment, pain, swelling, and giving way of the knee) and objectively (range of motion, stability, crepitation, isokinetic strength testing, and radiological changes of the knee), the groups did not have any significant differences in the 5- to 9-year results. Also, the final evaluation results using the IKDC and the Lysholm and the Marshall knee scores were similar in both groups. However, there were significantly more subsequent knee surgeries in the injured knee in group B than in group A. CONCLUSIONS: Our results show no large differences between patients with an isolated ACL tear and those with an ACL tear with accompanying injuries 5 to 9 years after an ACL reconstruction with a bone-patellar tendon-bone autograft. Tibiofemoral osteoarthritis was quite rare, and this may be partly attributable to the fact that the ACL reconstructions were successful, so that all the knees were stable at the re-examination. However, the future will show the final outcome for the patients.

The incidence of patellofemoral osteoarthritis and associated findings 7 years after anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft.

To evaluate the development of postoperative patellofemoral osteoarthritis, we performed a retrospective clinical and radiographic study of 100 patients who had undergone anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft an average of 7 years before the follow-up. Radiographic evaluation showed no patellofemoral osteoarthritis in 53 patients (group I), mild osteoarthritis in 34 patients (group II), moderate osteoarthritis in 12 patients, and severe osteoarthritis in 1 patient (group III, moderate and severe changes). The average shortening of the patellar tendon was 2.4 mm in group I, 3.9 mm in group II, and 6.8 mm in group III. The placement of the femoral or tibial tunnel of the graft, as measured from lateral radiographs, did not correlate significantly with the degree of patellofemoral osteoarthritis. Patients who developed patellofemoral osteoarthritis experienced worse final outcomes, were more often dissatisfied with the condition of the operated knee, experienced more frequent pain and swelling in the knee joint, and had poorer range of motion and poorer quadriceps muscle strength than did patients without patellofemoral osteoarthritis. Only three patients had an unstable knee, and degenerative changes in the tibiofemoral joint were uncommon.

Mucin MUC1 is seen in cell surface protrusions together with ezrin in immunoelectron tomography and is concentrated at tips of filopodial protrusions in MCF-7 breast carcinoma cells.

MUC1, a transmembrane member of the mucin family, is believed to have anti-adhesive properties because of its highly sialylated, extended, and rigid rod-like conformation. The ERM proteins (ezrin, radixin, and moesin) function as membrane-cytoskeletal linkers. MUC1 and ezrin are enriched in microvilli in MCF-7az breast carcinoma cells. Similar localization was also found in peripheral membrane areas and in filopodium-like protrusions. Whereas ezrin was consistently detected in the cell-cell contact region, MUC1 was less frequently found there. MUC1 was distinctly expressed in long filopodial protrusions and was highly concentrated at their tips, which also contained ezrin, whereas F-actin was found along the stalk. This localization of MUC1 suggests a role for MUC1 in transient cell structures of migrating cells and transient cell adhesion. No direct association has yet been found between MUC1 and ezrin. However, both MUC1 and ezrin had a similar overall distribution pattern in microvilli and filopodium-like protrusions in immunoelectron tomography. In addition, MUC1 and ezrin showed spatial association, because several 10-nm gold particles used to decorate ezrin were seen in the vicinity close to the clusters of 5-nm gold particles decorating MUC1. Therefore, MUC1 appears to be associated with ezrin, but the nature of this association requires further study.

The comparison of hypertonic saline (7.5%) and normal saline (0.9%) for initial fluid administration before spinal anesthesia.

Hypertonic saline can be used for initial fluid administration before spinal anesthesia. It is effective in small-volume fluid resuscitation. This randomized double-blinded study compared the effects of 7.5% hypertonic saline (HS) and 0.9% normal saline (NS) in doses containing 2 mmol/kg of sodium in 40 ASA physical status I-II patients undergoing arthroscopy or other lower limb surgery under spinal anesthesia. We infused 1.6 mL/kg of HS or 13 mL/kg of NS for initial fluid administration before spinal anesthesia induced with a 10-mg dose of 0.5% hyperbaric bupivacaine. Etilefrine was administered to maintain mean arterial pressure at > or =80% of its control value. Systolic and diastolic blood pressure, heart rate, and cardiac index did not differ between the groups, and the amount of etilefrine administered was similar in the treatment groups. In all our patients, the plasma sodium concentrations were within the normal range after surgery and serum osmolality was within the normal range after spinal anesthesia. The time and the volume of the first micturition were similar in both groups, despite the much smaller amount of infused free water in the HS group. We conclude that 7.5% HS was as good as NS for the initial fluid administration before spinal anesthesia when the amount of sodium was kept unchanged.

Anterior knee pain 7 years after an anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft.

In order to evaluate the occurrence and predicting factors of anterior knee pain in patients after an anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft, a functional, clinical and radiographic evaluation was performed on 91 patients on average 7 years after the surgery. Also, the isokinetic muscle torque was measured. At 7 years, anterior knee pain, as classified by the International Knee Documentation Committee (IKDC), was absent in 40 patients, mild in 47 patients, and moderate in 4 patients. None was classified as suffering from severe anterior knee pain. In the logistic regression analysis of predicting factors (forward-stepping), knee extension torque deficit of the operated limb was the only factor that showed significant association with anterior knee pain. The other objective measurements of the knee (flexion torque deficit, range of motion, stability evaluation, and radiographic evaluation of the knee) were not associated with anterior knee pain. Subjectively and not surprisingly, the patients without anterior knee pain were more often satisfied with the overall outcome than the patients with anterior knee pain. Also, the Lysholm and Marshall knee scores and the final outcome in the IKDC rating scale were significantly better in patients without than with anterior knee pain.

Bone-patellar tendon-bone reconstruction of the anterior cruciate ligament. A long-term comparison of early and late repair.

Ninety-one patients were assessed 5-9 years after an anterior cruciate ligament reconstruction (bone patella-tendon bone autograft). Forty-eight patients had been treated within 6 weeks of the injury (Group I) and 43 patients more than 3 months after the injury (Group II). 73 patients had either a normal or nearly normal final outcome. The mean Lysholm score was 82 and the mean Marshall score was 42. Eighty nine patients had normal or nearly normal stability in the operated knee when compared to the contralateral joint. In none of these results was there any significant difference between the groups. Results of functional and of isokinetic strength tests, as well as the presence of anterior knee pain, were also similar in both groups. However, patients with early reconstruction had fewer degenerative changes in the tibio-femoral joint and were more satisfied with the result. They also returned to their pre-injury level of sports activity more often than those patients in the late reconstruction group.