Biomedical subjects
Publications and source records attributed to G G Poehling.
Chronic ulnar wrist pain is both difficult to diagnose and difficult to treat effectively. A number of anatomic derangements have been reported as potential causes of this pain. We discuss a patient with pain on the ulnar side of the wrist and an arthroscopically diagnosed disruption of the ulnolunate ligament. This was an isolated lesion, and the patient responded well to debridement.
Dislocation of the tibiotalar joint without associated fracture is rare. We have presented a case of open anterolateral ankle dislocation with complete ligamentous disruption. In contrast to reports that internal fixation is not required to maintain reduction of tibiotalar joint dislocation, we found this dislocation to be grossly unstable, requiring both a syndesmotic screw and a calcaneotalotibial transfixing pin for stabilization.
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Panner's disease, or osteochondrosis of the capitellum, may actually be a continuum of disorders. In the past, such lesions were treated conservatively with surgery as a final option. With the advent of arthroscopy, a diagnosis can be made, and treatment with limited invasiveness instituted. This article reviews the diagnostic and therapeutic advantages of arthroscopic techniques in the treatment of Panner's disease.
Although arthroscopy represents a new and dynamic diagnostic technique for evaluating the wrist, specific indications for arthroscopic intervention in the wrist are not defined. To place this technique in perspective, we review our experience with 54 consecutive arthroscopies of the radiocarpal and midcarpal joints in 53 patients with chronic wrist pain. On the basis of this review, we believe arthroscopy is indicated for the diagnosis of wrist pain of longer than 3 months' duration. Defects of the triangular fibrocartilage and lesions of the articular cartilage, including loose bodies, are detectable and easily treated with wrist arthroscopy.
Arthroscopic surgical techniques are well suited for the removal of diseased tissue. This article illustrates anecdotally some of the feasible arthroscopic "-ectomy" procedures of the wrist: centrum excision of the triangular fibrocartilage complex following injury; synovectomy in the management of wrist rheumatoid arthritis; proximal row carpectomy for degenerative arthritis; and hemiresection of the distal ulna.
Severe flexion contractures of the proximal interphalangeal joint that are present at birth affect both sexes equally, often involve several digits of the same hand, and show no predilection for the small finger make up a distinct subgroup of the deformity known as camptodactyly. In this series, 20 digits with such severe flexion contractures were treated surgically. In eight digits, the flexor digitorum superficialis tendon was lengthened with or without release of contracted palmar structures. There was no improvement in these digits. In the other 12 digits, the extensor mechanism was realigned and augmented by release or transfer of the flexor digitorum superficialis tendon. All 12 of these digits had good (n = 10) to fair (n = 2) improvement in active and passive extension while retaining adequate flexion, although 9 still had some residual flexion contracture. In this type of camptodactyly, extensor mechanism anomalies appear to be the primary lesion.
We administered 0.5% bupivacaine 30 ml either with or without adrenaline 5 micrograms ml-1 randomly to 16 healthy outpatients, to determine the efficacy of local and intra-articular local anaesthesia for knee arthroscopy and whether or not adrenaline should be added to intra-articular bupivacaine. Bupivacaine concentrations were measured in plasma obtained 15, 30, 45 and 60 min after intra-articular injection. Patients receiving bupivacaine with adrenaline had significantly smaller plasma concentrations of bupivacaine at all times than did patients receiving plain bupivacaine. The maximal concentrations of bupivacaine in the plain group (median 515 ng ml-1, range 46-875 ng ml-1) were greater than those in the adrenaline group (median 33 ng ml-1, range 7-125 ng ml-1) (P = 0.001). All patients found the anaesthetic satisfactory. We conclude that intra-articular/local anaesthesia is satisfactory for outpatient arthroscopic surgery, and that adrenaline should probably be added to bupivacaine before intra-articular injection.
Isolated cold stress testing was performed on 72 healthy subjects in order to evaluate the normal thermoregulatory potential of vessel beds in the acral areas of the lower extremity. Two patterns of response were demonstrated: a cool response in approximately 80% of subjects, and a warm pattern in approximately 20%. In the former, the responses to cold stress were more active and the temperatures lower; in the latter, there was little change in temperature in response to the cold stress. Both patterns correlated strongly with initial temperature, and neither pattern correlated with age, sex, or smoking habits. No subjects reported pain, numbness, or discomfort during the test. This study demonstrated that wide variations in thermoregulatory flow were possible without clinical symptoms, and suggested that nutritional blood flow was adequate to meet metabolic demands despite thermoregulatory modulation.
Toe phalanges with attached periosteum can be transferred to hands with congenital aphalangia, constructing rudimentary digits with growth potential. Using a volar technique, rather than the traditional dorsal method, allows stabilization of the constructed metacarpophalangeal joint and maximizes flexor function.
Although only a small number of children with cerebral palsy have indications for surgical treatment of dynamic or structural upper-extremity deformities, orthopedic surgery does improve function and appearance of the involved hand, particularly in spastic hemiplegia. For further assessment of the patient after careful physical examination, myoneural nerve blocks and dynamic electromyography are useful. Physical and occupational therapists have an important role as crucial links among parents, patients, and physicians. Surgeons can try to prevent deformity with splints; however, their use in prevention of deformities of the hand has not been validated by scientific studies. Shoulder deformities can be managed with myotomies, tendon transfers, and (if fixed) osteotomies; rarely is arthrodesis used. Elbow flexion and dynamic or fixed deformities greater than 60 degrees are treated by lengthening of the muscles and tendons. Pronation deformities of the forearm are managed by myotomies, lengthenings, and tendon transfers. Wrist flexion deformities can be corrected with tendon lengthenings and transfers. The best results have been obtained with transfer of the flexor carpi ulnaris to the extensor digitorum communis. Finger flexion deformities can be managed satisfactorily with Z-lengthenings of the flexor digitorum superficialis in the forearm; rarely is it necessary to lengthen the flexor digitorum profundus. For adduction deformity of the thumb, division of the proximal or distal insertions of the adductor pollicis and release of the first dorsal interosseus muscle from the first and second metacarpals are preferred.
This article analyzes meniscal injuries seen in 10,117 knee arthroscopies. The information was compiled by a centralized data base at Surgical Data Management. The study suggests two patterns of meniscal injuries, degenerative and traumatic. Injuries to the menisci occurring with an associated anterior cruciate injury, radial tears, and tears within 3 mm of the meniscosynovial junction are associated with a younger and more active patient who is more likely to sustain a traumatic or sports-related injury. Tears described as complex, horizontal cleavage, and flap tears are associated with an older age group and follow a more degenerative pattern.
Elbow arthroscopy is a useful diagnostic and therapeutic tool for the orthopedic surgeon. In the standard technique, the patient is positioned supine with the arm suspended overhead and an anterolateral portal is used. We have modified this technique by placing the patient in a prone position and using a proximal medial portal. Use of the prone position improves scope mobility, facilitates joint manipulation, and provides more complete intraarticular visualization. This technique simplifies the treatment of a wide variety of elbow pathology, including loose bodies, osteochondritis dissecans, persistent synovitis, suspected cartilaginous lesions, posterior osteophytes, selected radial head fractures, and chronically undiagnosed painful elbows.
Thermoregulatory abnormalities are well known but poorly understood phenomena. Pathologic alterations of microvascular blood flow occur in a variety of diseases of the foot, and often cause severe functional impairment. The structure, function, and methods for testing thermoregulatory abnormalities are reviewed. Pathologic manifestations of abnormal thermoregulation are also discussed.
Reflex sympathetic dystrophy (RSD) of the knee is an extremely difficult problem to treat. This study examined the possible relationship between isolated injury to the infrapatellar branch of the saphenous nerve (IPBSN) and the etiology and natural course of RSD. Thirty-five patients with clinically significant sympathetic dystrophy of the knee were examined retrospectively. All patients (100%) had clinical evidence of insult to the IPBSN. Thirty-three patients (94%) were found to have vasomotor instability as measured by isolated cold stress testing (ICST). All patients in this population of 33 were treated with vasoactive therapies. Subjective improvement was noted in 20 patients (p = NS). Initial ICSTs of improved and unimproved patients were compared. Baseline temperatures were significantly warmer in patients who improved with therapy (p less than 0.05), and a warmer trend was evident throughout all phases of the test in those who improved compared with those who did not. Eighty percent of patients treated within 1 year improved with one or more vasoactive therapies, whereas only 44 percent improved when treatment was started after 1 year, indicating a significant population difference (p less than 0.05).
This first of three articles on arthroscopy of small joints is a brief overview of the current arthroscopes and the modifications that have made arthroscopy of small joint spaces possible. Those modifications include angulation at 25-30 degrees, improved low-light, high-resolution chip cameras, and use without a bulky camera adapter. The largest possible arthroscope should be used, but size is limited in diameter to 2.0 mm for the distal radioulnar and temporomandibular joints, 2.7 mm for the midcarpal joint, and 3.0 mm for the radiocarpal joint. The need to have high-quality repair service available is stressed.
Treatment of the anterior cruciate ligament (ACL)-deficient knee using an arthroscopic technique and freeze-dried allograft tendons in 23 patients was studied prospectively. Accurate placement of drill holes and anchoring positions for the allografts was effected through a standard arthroscopic approach combined with a 3 cm incision on the medial tibial flare. Candidates for reconstruction were those who were unable to tolerate brace therapy and who had no degenerative arthritis. The 23 patients were drawn from a group of 60 treated patients because their follow-up had been greater than or equal to 1 year. Their knees were assessed preoperatively and postoperatively with a Lysholm knee rating scale, Lachman test with KT-1000 arthrometric quantitation, pivot shift, Biodex test, and radiographs. Knee rating values improved in all knees, and only one patient had a significant deterioration in the KT-1000 reading. All patients with at least 20 months follow-up have resumed their preinjury activity levels.
This is the second in a series of articles on arthroscopy of small joints. Hand instrumentation for small joint arthroscopy has been adapted from instruments previously developed for large joint arthroscopy. They have been downsized and altered for use in the smaller confines of joints such as the radiocarpal, temperomandibular, and midcarpal articulations. Although smaller, the instruments must remain strong and easy to use. Each instrument should perform a simple function. Their shape must conform to the joint and they should be smooth to minimize the risk of articular cartilage damage. We have found several instruments that have been helpful in arthroscopic surgery of the wrist.