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Knee function after patellectomy and cruciform repair of the extensor mechanism.
When patellectomy is performed, the objectives should include restoration of a moment arm, centralization of the extensor mechanism, adequate range of motion, and cosmesis. The cruciate repair of the extensor mechanism described in this report has been developed to meet the aforementioned objectives. Eight patients with 12 patellectomies described herein were examined with Cybex testing of the knee at a follow-up period of 18 months to 20 years (mean, 56 months). A four-quadrant tissue dissection of the patellar soft-tissue enclosure was reconstructed in a cruciform pants-over-vest fashion, with the superomedial flap containing the vastus medialis insertion on top. This "soft-tissue" patella attempts to provide a greater moment arm than simpler repairs. This study examines whether this construct restored the torque of extension while concomitantly facilitating centralization of the extensor mechanism. Cybex testing of both knees examined both extensor and flexor function with specific regard to the ratio of extensor to flexor forces. Patients with patellectomies had few subjective complaints, with a mean knee score of 94 (median, 100). The extensor torque was not completely restored and there was a moderate decrease in the quadriceps function, both subjectively and objectively as measured by Cybex testing. The authors also found that in patients with unilateral patellectomies, the ratios of extension to flexion function, a parameter not yet reported in the literature, were significantly different between the normal and patellectomized knees. The same extension to flexion ratios were seen in patients with bilateral patellectomies. Because patients with patellar pathology requiring patellectomy frequently have chronic and bilateral disease, comparative functional evaluation may be difficult.(ABSTRACT TRUNCATED AT 250 WORDS)
[A histological study of the experimentally damaged ligamentous apparatus of the joints in rabbits treated with celeston].
A histological study was made on experimentally damaged ligament apparatus of the ankle joint of rabbits, treated with celestone, divided into three groups: celestone was administered immediately after the damage in the first group. Morphological changes were manifested slightly. Celestone was administered on the 20th day after the damage in the second group. A manifested chronic productive inflammatory process with hyalinization was established morphologically. The most manifested changes were found in the control group of rabbits, which were not treated with celestone. Intraarticular, administration of celestone in ligament damages immediately after trauma prevents occurrence of severe fibrous changes and contributes for functional recovery of the ligament apparatus.
[The effect of exercise on the normal and reconstructed anterior cruciate ligament in rabbits].
The effects of exercise on the biomechanical properties of the normal anterior cruciate ligament and bone specimen were investigated in two groups of rabbits: the one group with seven rabbits aged 7-8 months and the other with nine rabbits of 13-14 months. Four weeks of exercise produced significant increases in the maximum failure load, total absorbed energy to failure and stiffness in group of younger rabbits, but these changes were not seen in the older rabbits. Exercise effects on the remodelling of the reconstructed ACL were further studied in the two groups of rabbits, by observing macroscopic, histological, and biomechanical changes. While histologically normally structured ligament-bone junctions were seen partially in all the specimens, the specimen of the group with four weeks of exercise after 21 weeks after reconstructive surgery, showed a significant increase in stiffness of the reconstructed ACL. Macroscopically a glittering appearance was seen more frequently in the reconstructed ligament when compared to that of a cage-confined non-exercised group of rabbits.
PROLOTHERAPY VERSUS OPERATIVE FUSION IN THE TREATMENT OF JOINT INSTABILITY OF THE SPINE AND PELVIS.
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SPRAINED ANKLES. I. ANATOMIC LESIONS IN RECENT SPRAINS.
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[CALCIFYING AND OSSIFYING ARTHROPATHIES AND PARA-ARTHROPATHIES OF THE KNEE].
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Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers.
Eighty patients with persistent clinical and functional instability of the knee due to anterior cruciate ligament insufficiency underwent the operation reported, in which one-third of the patellar ligament substitutes for the cruciate ligament and extraarticular tendon transfers, medial and lateral, augment the substitution. The patients were followed for a minimum of two years, and fifty returned for personal evaluation. The average follow-up was thirty-three months, with a range of two to five years. There were thirty-five male and fifteen female patients. The average age was twenty-three years. The average interval from initial injury to the index operation was two years. Meniscal tears and articular changes were noted in most of the patients. Forty-three (86 per cent) of the fifty patients had at least one torn meniscus, twenty-seven patients (54 per cent) had significant degenerative articular changes, and fourteen (28 per cent) had patellar articular changes. In the procedure described, eccentric placement of the tibial and femoral tunnels for more accurate placement of the patellar ligament substitute is essential. The over-all results were graded as excellent in thirty knees, good in seventeen, fair in one, and a failure in two. One knee that was classified as a failure showed excellent stability, but the patient had significant pain from chondromalacia of the patella, while significant pain and hyperesthesia from a neuroma was the reason for failure in the second patient.
THE CORACOCLAVICULAR JOINT AND RELATED PATHOLOGICAL CONDITIONS.
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[Possibilities of gene therapy in traumatic and degenerative articular lesions. Current status of experimental and initial clinical applications].
Soft tissue injuries often represent the greatest clinical problem. Not only do many of the most frequently injured tissues, such as the cruciate ligaments and articular cartilage, have very limited capabilities for spontaneous repair, but they also respond poorly to surgical or non-surgical intervention. In this article we try to define the role of growth factors in these conditions and to outline concepts for future treatment based upon modulation of the native repair response. We suggest that gene transfer could improve the management of such injuries, particularly when used as vehicles for the targetted delivery of growth factors.
[Experimental study of intra-articular carbon fibers in the knee of the dog with and without preservation of the anterior cruciate ligament].
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Knee dislocations: where are the lesions? A prospective evaluation of surgical findings in 63 cases.
OBJECTIVE: To evaluate soft-tissue injury patterns in a large series of patients with knee dislocations to identify frequency and associations that may aid in surgical planning. DESIGN: Prospective clinical study. SETTING: Two institutions, both level I trauma centers. PATIENTS: Sixty patients with 63 dislocatable knees. RESULTS: Cause of injury was motor vehicle injury in 34 patients, sports in 23 patients, and falls in 3 patients; 71% of knees studied had bicruciate injuries. Eight knees had associated major intraarticular fractures. Vascular disruption occurred in 14% of knees. Peroneal nerve palsies occurred in 14% of knees. All injured knees with complete peroneal nerve palsies had anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament disruptions. The incidence of vascular injury was the same for patients injured in sports as for those injured in road trauma. Reattachable ligamentous avulsions occurred in 19% for anterior cruciate ligament, 51% for posterior cruciate ligament, 64% for medial collateral ligament, and 84% for lateral collateral ligament injuries. Certain injury patterns also had a high association of tendon and capsule avulsions. Proximal lateral collateral ligament injuries were commonly associated with popliteus tendon avulsions and seldom with distal biceps avulsions. Distal lateral collateral ligament injuries were commonly associated with distal biceps avulsions and seldom with popliteus tendon avulsions. Reattachable meniscal capsular avulsions off the tibia occurred predominantly when the collateral ligament injury was a distal avulsion. CONCLUSIONS: This study showed a wide variety of injury patterns. Knees had to have at least two ligaments injured to be dislocatable but not necessarily both cruciate ligaments. Sports injuries have the same pattern of injury as motor vehicle accidents, suggesting similar forces of injury. The study demonstrates a high incidence of reattachable avulsion injuries to ligaments and soft tissues in dislocatable knees. These may not be as easily dealt with if surgery is delayed beyond 3-4 weeks.
[Pathomorphology of the wrist joint in malunion of the distal radius after osseous fracture healing].
Morphological changes subsequent to malunion of distal radius fractures involve altered bone density along articular surfaces and wrist ligaments. The inclination of articular surfaces of the scaphoid and lunate in frontal and sagittal planes frequently leads to a dorsal dislocation of the distal fracture fragment. X-ray densitometry of subchondral mineralization shows zones of higher density along the palmar articular border, resulting from excentric load transmission. Typical morphological changes involving wrist ligaments are demonstrated and analyzed.
Interventions for preventing ankle ligament injuries.
BACKGROUND: Some sports, for example basketball and soccer, have a very high incidence of ankle injuries, mainly sprains. This contributes to ankle sprains being one of the most commonly treated injuries. OBJECTIVES: To assess the effects of interventions used for the prevention of ankle ligament injuries or sprains in physically active individuals from adolescence to middle age. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, MEDLINE (1966 to July 1996), EMBASE (1980 to September 1996), CINAHL (1982 to June 1996), and bibliographies of study reports. We also contacted colleagues and some trialists. Date of the most recent search: March 1997. SELECTION CRITERIA: Randomised or quasi-randomised trials of interventions for the prevention of ankle sprains in physically active individuals from adolescence to middle age were included provided ankle sprains were recorded. Interventions include use of modified footwear and associated supports, adapted training programmes and health education. DATA COLLECTION AND ANALYSIS: At least four reviewers independently assessed methodological quality and extracted data. Wherever possible, results of outcome measures were pooled and sub-grouped by history of previous sprain. MAIN RESULTS: Five randomised trials with data for 3954 participants were included. All trials involved young, active, mostly male adults participating in high-risk, usually sporting, activities. With the exception of ankle disc training, all prophylactic interventions entailed the application of an external ankle support in the form of a semi-rigid orthosis, air-cast brace or high top shoes. There was a significant reduction in the number of ankle sprains in people allocated external ankle support (Peto odds ratio 0.49; 95% confidence interval 0.37 to 0.66). This reduction was greater for those with a previous history of ankle sprain, but still possible for those without prior sprain. There was no apparent difference in the degree of severity of the ankle sprain prevented nor any change to the incidence of other leg injuries. The protective effect of 'high-top' shoes remains to be established. There was limited evidence for reduction in ankle sprain for those with previous ankle sprains who did ankle disc training exercises. REVIEWER'S CONCLUSIONS: This review provides good evidence for the beneficial effect of ankle supports in the form of semi-rigid orthoses or air-cast braces to prevent ankle sprain during high-risk sporting activities (e.g. soccer, basketball). Participants with a history of previous sprain can be advised that wearing such supports may reduce the risk of incurring a future sprain. However, any potential prophylactic effect should be balanced against the baseline risk of the activity, the supply and cost of the particular device, and for some, the possible or perceived loss of performance. Further research is indicated principally to investigate other prophylactic interventions and general applicability.
Role of the medial structures in the intact and anterior cruciate ligament-deficient knee. Limits of motion in the human knee.
We measured motion limits in human cadaveric knees before and after sectioning the anterior cruciate ligament and the medial structures. Sectioning the medial collateral ligament in an anterior cruciate ligament-deficient knee increased the anterior translation limit at 90 degrees of flexion but not at 30 degrees of flexion. The tibia displaced straight anteriorly without exhibiting the coupled internal rotation that occurred in intact and anterior cruciate ligament-deficient knees. A lateral 15 N-m abduction moment produced a coupled external rotation in the medial collateral ligament-deficient knee. This was in marked contrast to intact, anterior cruciate ligament-deficient, or combined medial collateral ligament and anterior cruciate ligament-deficient knees, in which an abduction moment produced a coupled internal rotation. Sectioning only the medial collateral ligament caused a small but significant increase in the abduction rotation limit, whereas larger increases in the abduction rotation limit occurred when the posterior oblique ligament and posterior medial capsule were cut in addition to the medial collateral ligament. Cutting the medial collateral ligament increased the external rotation limit. The increase was independent of whether the anterior cruciate ligament was intact or sectioned. Subsequent cutting of the posterior oblique ligament and posterior medial capsule further increased the external rotation limit.
[Enthesopathies. Radiography and xeroradiography compared].
The term "enthesis" designates the sites of tendon, ligament and articular capsule insertion to bone. Entheses are fundamental to the cybernetic regulation and correlation of postural and motion functions in the body. They also hold a key position in the locomotor system diseases. "Enthesopathy" is a disease occurring at these sites (primary enthesopathy), which can occur alone or together with different disorders, including inflammatory, degenerative, metabolic and traumatic conditions (secondary enthesopathy). Enthesopathy may lead to articular and non-articular manifestations: common sites of involvement include the spine and pelvis, femoral trochanter, humeral tuberosity, patella, olecranon and calcaneus. In acute enthesopathy, all the signs of acute inflammation may be present. In subacute or chronic forms, pain and tenderness localized in the entheses are found. Radiographic patterns include bone erosion, hyperostosis (enthesophytes), bone fragmentation and crystal deposits.
Imaging of the knee.
MR imaging has become the primary imaging modality of the knee. Its advantages include its noninvasive nature, multiplanar imaging capability, excellent soft-tissue contrast, and high resolution. The need for multiple imaging modalities is obviated, as the menisci, cruciate ligaments, synovium, articular cartilage, marrow, and periarticular soft tissues can be simultaneously evaluated. Other imaging modalities may occasionally be helpful in the evaluation of specific problems including CT in tibial plateau fractures, real-time ultrasound for the confirmation of a popliteal cyst or popliteal artery aneurysm, and arthrography for the detection of prosthetic joint loosening.
Posterior approach for arthroscopic treatment of posterolateral impingement syndrome of the ankle in a top-level field hockey player.
A case history of a 25-year-old field hockey player, a member of the German National Field Hockey Team, is presented. The patient could not remember any specific ankle injury, but since the World Indoor Championship in February 2003, he experienced significant but diffuse pain around the posterior ankle, especially while loading the forefoot in hockey training and competition. For 2 months, the patient was unable to run. Conservative treatment failed, and surgery was performed. Posterior ankle arthroscopy revealed a frayed posterior intermalleolar ligament and meniscoid-like scar tissue at the posterolateral ankle, indicating a posterolateral soft tissue ankle impingement syndrome. A concomitant inflammation of the posterolateral ankle and subtalar synovium was present. After arthroscopic resection and early functional aftertreatment, the patient returned to full high-level sports ability within 2 months.