Operative versus nonoperative treatment of acute Achilles tendon ruptures: a quantitative review.

OBJECTIVE: To determine the optimal treatment of acute Achilles tendon ruptures. DATA SOURCES: A comprehensive search for all of the English articles published between 1959 and 1997. STUDY SELECTION: All of the articles were reviewed independently by at least three of the four authors to decide on eligibility based on predetermined criteria. Disagreements were discussed and then settled, if necessary, by a majority vote. DATA EXTRACTION: Eligible studies were reviewed independently, and data were extracted by using standardized coding forms. Inconsistencies in data extraction were settled by discussion and majority vote. The main outcomes extracted were strength, time to return to work, frequency of return to sports, rerupture rate, and complications. Complications were divided into major, moderate, and minor categories. DATA SYNTHESIS: The overall rerupture rate was 2.8% for operatively treated and 11.7% for nonoperatively treated patients (p < 0.001). The rate of minor and moderate complications in operatively treated patients was 20 times that of nonoperatively treated patients. The difference in rates for major complications was not statistically significant. CONCLUSIONS: Although operative treatment provides a reduced rerupture rate compared with nonoperative treatment, the minor and moderate complication rate of operative treatment is 20 times greater. Treatment should be individualized to the concerns and health of the patient. Future clinical trials are necessary to determine the optimal method of both operative and conservative treatment.

Percutaneous in situ fixation of slipped capital femoral epiphysis using two threaded Steinmann pins.

Twenty-six patients with 34 slipped capital femoral epiphyses were treated by percutaneous in situ pinning with two 5/32-inch threaded Steinmann pins. Twenty-three patients with 31 hips were followed-up until the time of epiphyseal closure and pin removal. The average time to closure was 8.5 months (range, 3-25). The average operative time for pinning was 53 min (range, 18-115). The average operative time for pin removal was 42 min (range, 12-132). Complications included two progressive slips, two poorly placed pins, one pin breakage during removal, and one case of capital necrosis. This technique is a quick, efficient means of stabilizing the slipped capital femoral epiphysis, with case of hardware removal.

Non-operative treatment of ruptures of the anterior cruciate ligament in middle-aged patients. Results after long-term follow-up.

We retrospectively reviewed the records of fifty-two patients who had had a rupture of the anterior cruciate ligament between the ages of forty and sixty years, to determine the results of aggressive non-operative treatment. We were able to locate and re-examine thirty of these patients (mean age, forty-six years) after a mean duration of follow-up of seven years (range, five to thirteen years), and to assess the clinical, radiographic, and functional results. The mean score, according to the scale of Lysholm and Gillquist, was 82 points; eight of the eleven patients who had combined ligamentous injuries had a score of less than 84 points (symptoms with daily activities). Thirteen substantial reinjuries had occurred in eleven patients (37 per cent) during the follow-up period. Twenty-nine patients (97 per cent) had a grade-2 or 3 Lachman test, and a positive pivot-shift test was elicited in twenty-five patients (83 per cent). Plain radiographs revealed minimum or no changes in twenty-six patients (87 per cent). Magnetic resonance imaging in nine patients revealed scarring of the remnant of the anterior cruciate ligament to the posterior cruciate ligament in six. The mean difference in anterior-posterior laxity between the injured knee and the normal, contralateral knee, as measured with the KT-1000 arthrometer, was five millimeters at twenty pounds (eighty-nine newtons). Twenty-five (83 per cent) of these thirty middle-aged patients, who had had guided rehabilitation and had modified activity, had a satisfactory outcome without an operation. However, a few patients, who had combined instabilities and who wished to resume competitive sports activity that required pivoting, were dissatisfied. Such patients may need operative reconstruction to achieve their goals.