Biomedical subjects
Publications and source records attributed to R Seil.
Isolated avulsion of the biceps femoris tendon is a relatively rare condition. We report a case of a 43 year-old soccer player with a rupture of the biceps femoris tendon which occurred in a hyperextension of the knee. Based on this case, we discuss the literature referring to injury pattern and treatment.
INTRODUCTION: Our report shows a rare case of suprascapular nerve palsy due to a SLAP-related ganglion cyst resulting in isolated weakness of the infraspinatus muscle. CASE REPORT: We report on a 31-year old volleyball player with severe shoulder pain. A ganglion cyst was excised in an open procedure and was completely resolved in a postoperative magnetic resonance imaging (MRI). But the patient again had pain and disability 7 months after this procedure. A renewed MRI scan showed a cystic mass in the spinoglenoid notch. An electromyography revealed an isolated lesion of the suprascapular nerve. The patient was treated by shoulder arthroscopy with refixation of a type-II-SLAP-lesion and drainage of the cyst formation. At latest follow-up 29 months after surgery, the patient's pain and shoulder function improved with a constant score of 94 points. A MRI scan documented complete cyst resolution. CONCLUSIONS: Treatment options for ganglion cysts at the spinoglenoid notch are various and can be handled in conservative and operative ways. We believe that the arthroscopic concept with the management of a SLAP lesion as the cause of cyst formation, and the drainage of the ganglion is an effective way with low surgical morbidity that shows good postoperative results.
Valgus-producing osteotomy of the proximal tibia is a well-established treatment for medial femorotibial osteoarthritis in the varus knee. The ideal patient is active, under 55 years of age, has a stable varus deformity of less than 10 degrees, a good bone stock, and an osteoarthritis stage that is restricted to the medial compartment of the knee. Coventry reported a failure rate in proximal tibial osteotomy to be significantly higher when the postoperative alignment was less than 8 degrees of anatomical valgus. Hernigou noted better clinical long-term results in cases with a precise correction of malalignment. There are different preoperative planning methods varying between simple estimates of correction angles and specific radiographic planning tools. The reproducibility of operative outcome with regard to a predictable anatomic alignment and functional recovery must have high priority. This chapter deals with different preoperative planning methods to improve the reliability of surgical results after tibial osteotomy.
In high tibial closing-wedge osteotomies (HTO), closure of an osteotomy gap after resection of a bony wedge can be associated with a fissure of the medial cortex of the tibial head (MCT). The effect of a broken MCT on the recurrence of varus deformity is disputed. In this study, serial roentgen stereometric analysis (RSA) was used to determine the fixation stability of a rigid internal "L" plate after HTO. Full weight lower limb radiographs were used to determine the sagittal alignment in patients with varying degrees of varus malalignment and correction over time. Forty-two patients with varus gonarthrosis stage I-III (Ahlback) were treated with HTO and internal fixation with an L-shaped rigid plate. Patients were followed by serial RSA, conventional radiographs, and clinical evaluation (Hospital of Special Surgery score) over a 12-month period. In 19 of 42 successive patients, an average wedge size of 6.9 degrees was resected leaving the MCT intact (group 1). In 23 of 42 of patients, the MCT was unintentionally fissured during surgery when an average 10.3 degrees -wedge was resected (group 2). In group 2, RSA revealed a fivefold increase in lateral displacement of the distal tibial segment within 3 weeks after HTO. Twelve weeks after HTO, translations between tibial segments were below the accuracy of the RSA setup in the majority of patients. Group 1 patients demonstrated a higher initial fixation stability, less occurrence of varus deformity, and a higher HSS score compared to patients with larger wedge sizes and frequent fracture of the MCT (group 2). Before bone healing is achieved, the integrity of the MCT plays a crucial role for the clinical and radiological outcome after HTO.
Anteromedialization of the tibial tubercle (Fulkerson operation) predictably leads to pain reduction and better function in initial and moderate patellofemoral arthritis. This has been shown in the literature and is supported by our own results. The indication is based on symptoms, clinical evaluation, X-rays, and MRI. The Fulkerson operation combines recentering of the patella and reduction of patellofemoral pressure. Aftertreatment together with rehabilitation last for 6-8 months because anteromedialization leads to temporary destabilization of the proximal tibia. Proximal tibial fracture is a complication of Fulkerson operation if the tibia is stressed too early.
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PURPOSE: Numerous new all inside meniscus repair techniques using biodegradable fixation devices have become available in the last years. Few studies have dealt with the biomechanical properties of these implants so far. The aim of this study was to analyze meniscus repairs under cyclic loading conditions for different fixation devices (Meniscus Arrow, Clearfix Meniscal Screw, Meniscal Dart, BioStinger) and to compare them to standard suture techniques. MATERIAL AND METHODS: Eighty meniscus repairs on 27 medial porcine menisci were performed. For biomechanical testing loosening, number of failures, failure modes and failure loads were evaluated under cyclic and maximum loading conditions. Testing was performed on a materials testing machine. RESULTS: During cyclic loading 10 out of 40 (25%) fixation devices failed. A gap appeared between the 2 parts of the meniscus within the first loading cycles. The failure strengths obtained with the 4 meniscus fixation devices did not differ significantly (Meniscus Arrow: 44 N; Clearfix Meniscal Screw: 35 N; Meniscal Dart: 33 N; BioStinger: 54 N). Besides for the BioStinger, the values of the sutures were significantly higher. The use of a stronger suture material (PDS 0) increased the failure load significantly. During maximum loading the fixation devices failed by both pull-out of the head or the tip of the device, except for the BioStinger showing only pull-out of the head. All sutures failed by breakage, except for the PDS 0 horizontal sutures in which 50% of complete tissue failures could be noted. CONCLUSION: This study shows that meniscal fixation devices may fail under repetitive loading conditions. A gap appeared between the meniscal margins within the first loading cycles irrespective of the suture type and fixation device used. Both gapping and failure modes of the fixation devices may be design-specific. The maximum failure loads differed significantly between the bioabsorbable devices and the sutures. Stronger suture materials increased the failure loads significantly. To allow a complete evaluation of new meniscus fixation devices not only biomechanical, but also biological and clinical parameters need to be analyzed in forthcoming studies.
While the advantages of C-arm navigation in computer-assisted spine surgery are obvious, the accuracy of pedicle screw placement with virtual fluoroscopy still needs to be verified. The C-arm-based ION system (Medtronic Sofamor Danek) was used to navigate pedicle screw insertion in patients undergoing spinal surgery for various conditions. In a prospective study, a total of 160 screws were inserted in the first 30 consecutive patients since introduction of the system at our institution: 54 at the thoracic spine (highest level: TH4) and 106 at the lumbar spine. Computed tomography (CT) scans were performed postoperatively by two independent radiologists to control the accuracy of screw placement at the level of the pedicles after reconstruction of axial images according to Laine et al. The comparison of the calculated accuracy rate of pedicle screw placement using virtual fluoroscopy with reported results achieved with CT-based navigation shows similar results for virtual fluoroscopy and a remarkable increase of accuracy in comparison to reports on conventional pedicle screw placement.
The bone-patellar tendon-bone graft (BTPB) was the most commonly used graft for many years. The scientific database is more complete than for every other graft option. This review article presents the surgical techniques of ACL reconstruction with the BPTB graft, aspects of rehabilitation, clinical results, and postoperative problems with special emphasis on donor site morbidity.
After the first description of meniscus repairs in the literature it took nearly a century until they were routinely performed in orthopaedic surgery. The scientific basis for meniscus reconstruction needed to be elaborated, including the study of the anatomy, and for instance the vascularisation and the function of the meniscus. After the first experiences with open repair, several arthroscopic techniques have been developed. It has been shown that several factors could influence the healing rate of meniscus lesions. One of the major factors is knee stability. Meniscus repairs performed in conjunction with reconstruction of the anterior cruciate ligament (ACL) have shown higher healing rates (generally > 75%) than isolated repairs, either in stable (50-75% healing rate) or in unstable knees (< 50% in some studies). The localization of the tear is probably the most important factor influencing the healing rate of meniscus repairs. Peripheral tears which are located in the vascular zone of the meniscus heal better than centrally located tears in the avascular area. Many efforts have been provided to enhance the vascularity in this part of the meniscus. None of the proposed techniques have been proven to be definitively effective, or they are too demanding for routine use. Conventional meniscus suture techniques are time-consuming, technically demanding and necessitate incisions at risk for neurovascular structures. In order to simplify meniscus repair several new implants have been developed. They have different forms and are made of different materials among which some are biodegradable. The first clinical results with these techniques are encouraging. However, some new complications have been described. Their incidence and the fate of intraarticular biodegradable devices still has to be defined, especially in the long-term. The present study describes the actual knowledge of meniscus repair and presents the new techniques. It also shows that several questions concerning meniscus repair still need to be answered, and points out the need for further controlled studies.
The aim of this study was to analyze meniscal sutures under cyclic loading conditions for different suture types (vertical and horizontal mattress sutures) and suture materials (absorbable monofilament sutures: PDS 2-0; PDS-0, and PDS-1 USP). Testing was performed on medial porcine menisci, using a well-established biomechanical testing model with a complete longitudinal tear 3 mm from the periphery of the meniscus. Sixty specimens were used. One suture was tested at a time. During cyclic testing 100 load cycles were applied with a crosshead speed of 50 mm/min. Three different maximum loads (10 N, 20 N, and 40 N) were used. The preload was set at 5 N. After cyclic loading, the specimens were loaded until failure. During cyclic loading, a gap appeared between the two parts of the meniscus, and partial tissue failures were observed at the surface of the meniscus. Gapping was more marked with higher loads and with the weaker suture material (p < 0.001). Using PDS 0 and PDS 1 sutures, less partial tissue failures were observed compared to PDS 2-0 (p < 0.001). The ultimate failure loads after cyclic loading were higher with PDS-0 and PDS-1 sutures. With these suture materials vertical sutures were stronger than horizontal sutures (p < 0.05). Using PDS 2-0 this difference could not be found. These results show that the primary strength of meniscal sutures depends on the suture material. The frequency and the amount of gapping and partial tissue failures, which can be observed under cyclic loading, are less distinct with PDS-0 and PDS-1 compared to PDS 2-0. From a biomechanical point of view, PDS 0 and PDS 1 sutures are recommended for meniscal sutures to guarantee a high primary stability, a small amount of gapping, and few partial tissue failures.
The objective was to evaluate mid-term results after arthroscopic subacromial decompression (ASD) with special focus on the bias due to an application to social insurance for pension based on sickness disability. The study group consisted of 42 patients (28 male, 14 female). ASD was performed in 1993 or 1994 for impingement stage II. The mean age was 49.5 years. Thirty-nine patients (93%) were evaluated by an independent observer for an average follow-up of 3.5 years (range 1.5-5). Patients satisfaction with the outcome was assessed by a visual analog scale graded from 0 (extremely dissatisfied) to 10 (extremely satisfied). The functional result was assessed using the Constant score. At follow-up the mean VAS value was 6.4 +/- 3.4. The Constant score improved from 49.6 +/- 18.5 to 84.8 +/- 14.3. The subgroup of patients having applied to social insurance for pension had significantly worse results compared with the remaining patients: VAS: 4.9 +/- 3.1 vs. 7.5 +/- 3.1; Constant-Score: 76.1 +/- 12.7 vs. 88.3 +/- 13.5. The fact that patients try to get benefit from social insurance based on sickness disability significantly biased the outcome after ASD.
The objective was to evaluate long term results after removal of a popliteal cyst with special focus on recurrence rate and associated intraarticular pathology. Between 1982 and 1995 71 patients (23 women and 48 men between 21 and 75 years of age) underwent removal of a popliteal cyst. An additional arthroscopy of the knee joint was carried out in 51 consecutive patients starting in 1988. The mean follow up was 6.5 years (2 to 15 years), 66 patients (93%) were available. The subjective satisfaction with the outcome was assessed using a visual analogue scale (VAS) graded from 1 (highly satisfied) to 10 (highly dissatisfied). The popliteal region was evaluated by ultrasonography for recurrence of a cyst. During arthroscopy the predominant associated intraarticular pathologic finding was the lesion of the posterior horn of the medial meniscus (75%) and the lesion of the hyaline cartilage (90%). The cyst recurrence rate was 71%. In this subgroup grade III and grade IV chondral lesions were significantly more frequent (p < 0.001). Patients with a recurrence of the popliteal cyst rated the result significantly worse (7.6 +/- 2.3 vs. 3.4 +/- 2.3; p < 0.001). The recurrence rate was relatively high in the long term follow up. It depends strongly on the type of associated intraarticular pathology. Especially grade III and grade IV chondral lesions correlated significantly with recurrence of a popliteal cyst after removal. Therefore, the main goal of surgery should be the successful treatment of associated intraarticular pathologies.
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Arthroscopic techniques still represent the treatment of choice in osteochondral lesions of the talus (OLT). Open techniques may be used as an alternative or may be complementary to arthroscopic treatments. They are especially indicated in cases of large osteochondral lesions, difficult localisations and in cases of recurrent interventions. In addition to the type of treatment for the lesion itself, the choice of an ideal surgical approach is of paramount importance. Indications, operative technique, possible complications and rehabilitation are described in detail for each approach. Anterolateral, anteromedial, posterolateral and posteromedial soft-tissue approaches as well as medial and lateral malleolar osteotomies are discussed. If a distraction is not desired with arthroscopy, posteromedial and posterolateral soft-tissue approaches offer a good alternative for the treatment of posterior OLT. Osteotomy of the (medial) malleolus offers good visualisation of the medial talar dome. With the introduction of new techniques of osteochondral transplantations, the use of this approach is becoming more popular. However, it is an invasive technique and the risk of secondary osteoarthritis after malleolar osteotomy still needs to be determined.