Posterior cruciate condylar total knee arthroplasty. Average 11-year follow-up evaluation.

Forty-two total knee arthroplasties (TKAs) of the posterior cruciate condylar design performed from 1975 until 1978 were reviewed. Follow-up evaluations averaged 11 years. There were 21 knees each of osteoarthrosis and rheumatoid arthritis. The average postoperative knee score was 85.4 points. Thirty-nine knees (92.8%) were rated good or excellent, one (2.4%) was judged fair, and two (4.8%) were considered failures. Postoperative flexion averaged 104 degrees. Analysis of osteoarthritic versus rheumatoid arthritic subgroups demonstrated no significant differences in motion, alignment, or knee score. Roentgenographic review demonstrated no cases of femoral or tibial loosening, but one case of patellar component dislodgement was observed. Nonprogressive radiolucent lines were observed in 75% of the cases. Good results can be expected if satisfactory lower-extremity alignment is attained. Posterior cruciate ligament retention has provided a slightly improved postoperative range of motion. Residual problems appear to be centered about the patellofemoral joint.

Traumatic atlantoaxial dislocation without fracture of the odontoid.

Four cases of atlantoaxial dislocation without fracture of the odontoid have now been reported in patients surviving significant trauma. Experience with these cases suggest the following: 1. Atlantoaxial dislocation is compatible with survival and minimal or no long-term neurologic effects. 2. Reduction of the dislocation by traction is possible and has not resulted in significant complications, but marked instability can be present. Close medical supervision and frequent radiographic evaluation is mandatory. During reduction, the weight and angle of traction applied is changed in each phase of reduction (distraction, realignment, release). After reduction, physician-controlled, gentle flexion-extension radiographs are used to assess stability. 3. Traction should be started with light weights, care being taken to avoid overdistraction. A maximum of 15 lb traction was required for reduction in the present case. 4. Posterior surgical fusion is usually necessary because of residual instability and/or incomplete reduction, as demonstrated by postreduction supervised, gentle flexion-extension radiographs and/or CT scan. 5. There may be a small number of patients who can be treated by immobilization alone if a completely stable, anatomic reduction is obtained with traction.

Internal fixation compression arthrodesis of the ankle.

Sixteen patients were treated by internal compression arthrodesis of the ankle using cancellous screw fixation. Thirteen patients had a preoperative diagnosis of traumatic osteoarthritis, and three patients had rheumatoid arthritis. All patients were followed until clinical and roentgenographic evidence of union had been obtained (average, 15.1 months). Union was obtained in 15 of 16 cases (94%) by an average of 9.2 weeks. The average ankle evaluation score was 77 points, with 80% of the patients rated good or excellent. Suboptimal results were attributed to technical errors. Midtarsal motion averaged 18 degrees, and subtalar motion was present in the majority of patients after surgery. This technique provides a high union rate while permitting early mobilization of the adjacent hindfoot and midfoot joints with earlier return to satisfactory function.

Correction of alignment deformities during total knee arthroplasties: staged soft-tissue releases.

Preoperative evaluation consists of a series of radiographs and a careful analysis of the gait in order to estimate the amount of bone resection and soft-tissue release needed for successful arthroplasty. Graduated, surgical soft-tissue releases were used for realigning arthritic knees during arthroplasty. Medial, lateral, anterior, and posterior releases provide step-by-step correction for realigning markedly deformed joints. The procedure prevents "over-releasing" leading to ligamentous instability. At surgery the mechanical axis of the limb was used for knee realignment by use of a towel clip over the hip joint and palpation of the malleoli at the ankle; the center of the hip, knee, and ankle should be in a straight line. Elimination of abnormal moment (the tendency to produce motion about the normal axis) at the knee with weight-bearing was the goal for realignment. Proper alignment is the key to success and longevity in knee arthroplasty. Soft-tissue releases should be used with any type of instrumentation the surgeon desires. The patella must also be realigned.

Fibrous contracture of muscles following intramuscular injections in adults.

Periarticular fibrous muscle contractures in adults from repeated injections in the same site is predictable. The causes of joint contracture in children are many and complex, but in adults it seems certain that this phenomenon is the result of repeated injections of analgesics or other agents into 1 muscle area. Any drug if repeatedly injected locally may cause fibrosis of the muscle and subsequent joint contracture. Five cases of bilateral abduction contracture of the shoulder in adults including the first case of bilateral abduction contractures of shoulder and hip plus bilateral flexion contracture of elbow and extension contracture of a knee are reported. No underlying disease which might predispose to this fibrosis of muscles was noted. The frequency and period of injections were variable over several years. In all patients the interference in activtities of daily living were serious, but the deformities were corrected by release of the fibrous band with relief of discomfort and restoration of joint motion without recurrence. Noting the potential complication of repeated intramuscular injections in one area, this practice should be avoided whenever possible in adults, as well as in children.