Diagnosis and treatment of the plica syndrome of the knee.

Seventy-three knees with a symptomatic plica were managed using both conservative and operative methods. Twelve patients were successfully treated conservatively. Fifty-seven patients (sixty-one knees) underwent arthrotomy and partial synovectomy or a release of the plica through the operating arthroscope, and all but two returned to full activity. The results were considered excellent or good after an average follow-up of nineteen months.

Simultaneous and staged bilateral total knee arthroplasty.

Bilateral total knee arthroplasties were performed in twenty-six patients with severe rheumatoid arthritis and osteoarthritis. Twelve had simultaneous operations bilaterally and fourteen had separate, staged procedures. The improvement in the two groups of patients was statistically comparable to the relief of pain and the over-all restoration of function. There were no intraoperative complications. The postoperative morbidity was minimum and was not predominant in either group. Costs were greatly increased with the staged procedure.

Bilateral transpedicular decompression and Harrington rod stabilization in the management of severe thoracolumbar burst fractures.

Fifty-eight patients with severe thoracolumbar burst fractures were treated with bilateral transpedicular decompression, Harrington rod instrumentation, and spine fusion. Spinal realignment and stabilization was achieved by contoured dual Harrington distraction rods supplemented by segmental sublaminal wiring. Posterior element fractures were noted in 25 patients, 9 of whom had associated dural tears. Computed tomography was performed to assess the cross-sectional area of the spinal canal before surgery and after decompression. Patients at initial evaluation averaged greater than 67% spinal canal compromise. After surgery, successful decompression was accomplished in 57 patients. One patient required staged, anterior thoracoabdominal decompression and fibula strut grafting. At follow-up (average, 43 months; range, 25-70 months), neurologic improvement was found in 77% of the patients who initially presented with neurologic deficits. Thirty-four of 40 patients with incomplete paraplegia improved one or more subgroups on the Frankel scale. A solid fusion was attained in all 58 patients. No patient had a significant residual kyphotic deformity. Single-stage bilateral transpedicular decompression and dual Harrington rod instrumentation reliably provides decompression of the spinal canal and restores spinal alignment. The procedure allows early mobilization and provides an environment for solid fusion and maximum neurologic return.

Metastatic melanoma to the spine. Demographics, risk factors, and prognosis in 114 patients.

STUDY DESIGN: One-hundred-fourteen patients with metastatic melanoma of the spine were retrospectively reviewed. OBJECTIVE: The goal was to define the demographics, risk factors, and prognosis for this population. SUMMARY OF BACKGROUND DATA: The incidence of melanoma is increasing faster than any other cancer. Therefore, orthopedic and neurologic surgeons will be increasingly confronted by patients with spinal metastases from melanoma. However, the demographics, risk factors, and prognosis remain unclear. METHODS: From 7010 consecutive patients with melanoma, 114 were identified with clinically or radiographically evident spinal metastases. A comparison was made between these patients and the remainder of the population with melanoma seen at our institution using contingency table analysis with statistical significance determined by a chi-squared test. Survival data were represented by Kaplan-Meier curves, and log-rank testing was used for statistical comparisons. RESULTS: Risk factors associated with the development of these metastases included primary lesions that were ulcerated, deeper than 0.76 mm, or of Clark level II, or located on the trunk or mucosal surfaces. The median survival time for all patients was 86 days, but this was reduced in patients with more than one metastatic site in addition to the spine. CONCLUSION: The prognosis for most patients with spinal metastases from melanoma is dismal. However, patients with metastatic disease limited to the spine and one other organ may survive for a relatively prolonged time and may be candidates for surgical intervention directed toward symptomatic relief.

An algorithm for arthroscopy in the over-50 age group.

We conducted a retrospective study to identify the preoperative variables that correlated with a successful outcome for knee arthroscopy in patients over the age of 50. We mailed questionnaires to 94 patients (57 responded) and reviewed their medical records and radiographs. A modified Hospital for Special Surgery knee rating system was devised. The average follow-up was 33 months. The percentage of those who felt they had successful results decreased with time: 82.8% felt their knees had improved immediately after postoperative rehabilitation; this decreased to 78.1% at 6 months, 73.5% at 1 year, 65.5% at 2 years, and 50.0% at 3 years. Therefore, the subjective success rate was 67%. We performed statistical analysis of all variables to determine which had a beneficial or detrimental effect on outcome. In addition, we devised an equation to allow postoperative prediction of score. We found that age was not a factor and that radiographic findings had the greatest impact on postoperative results.

Foot and ankle injuries in classical ballet dancers.

The pathomechanics of dance injury are explained. Specific injuries are included, such as fractures, ankle sprains, anterior impingement syndrome, posterior impingement syndrome, flexor hallicus longus tendinitis, Achilles tendinitis, and stress fractures.

Management of severe musculoskeletal injuries of the upper extremity.

Limb salvage was successful in 25 patients treated for severe grade III upper extremity injuries. In a retrospective review of 20 men and five women, follow-up time averaged 26 months. These high-energy injuries were characterized by massive soft-tissue injury, highly comminuted fractures, and significant neurovascular injury. Farm, industrial, and vehicular accidents accounted for 80% of the cases. Over 50% of the patients had concomitant systemic and/or other significant extremity injuries. Initial treatment consisted of irrigation and debridement and fracture stabilization using external and/or internal fixation. An average of four additional surgical procedures was required to provide soft-tissue coverage and maximum possible functional recovery. Forty-eight percent of the extremities underwent free vascularized or pedicular flaps for coverage or reconstruction. At final follow-up observation, 12% of the extremities rated excellent, 20% rated good, 52% fair, and 16% were poor. Experience gained in managing these severe upper extremity fractures supports the following observations. (a) Grade III open fractures of the upper extremities are frequently associated with significant neural, vascular, and musculotendon injuries. (b) External fixation plays an important role in the stabilization of grossly contaminated fractures. (c) Residual functional disability is common, and most patients do not return to their previous occupation. (d) Staged reconstruction directed toward maximum functional return may take several years.

Rehabilitation of foot and ankle injuries in ballet dancers.

Classical ballet is an exacting art form with roots dating to the Italian Renaissance. The physical demands of dance class, rehearsal, and performance can predispose the dancer to injury. The foot and ankle are common sites of injury. Most injuries are caused by overuse rather than acute injuries. The purpose of this clinical report is to describe the initial treatment, as well as a structured program directed to the restoration of motion, strength, endurance, and proprioception essential for the successful return to dance. Additionally, specific rehabilitation techniques will be presented to assist the physical therapist in reducing those risk factors that may predispose a dancer to future injury. J Orthop Sports Phys Ther 1990;11(8):355-361.

Open fractures of the extremities. The case for open treatment.

Meticulous care of open wounds in open fractures is essential to prevent development of infection. Wounds should be treated by early excision and early delayed or secondary closure. Primary closure is not necessarily beneficial and can actually increase the risk of infection. Culture for aerobic and anerobic organisms should be obtained at initial examination, and antibiotic treatment should be started before wound excision. The experience at Duke University Medical Center, Durham, North Carolina, during the past 40 years has demonstrated that open treatment of open wounds is safe and highly successful in preventing gas gangrene and osteomyelitis.

Scaphoid fractures: assessment and treatment.

The scaphoid is the most commonly fractured carpal bone. The fracture pattern and its relationship to the blood supply have significant implications regarding treatment and prognosis. Prompt recognition and treatment are fundamental to successful management.

External fixation in the management of severe musculoskeletal trauma.

External fixation was employed in 33 open extremity fractures in 29 patients. These high energy injuries were characterized by massive soft tissue injury, contamination, instability, comminution, and/or segmental bone loss. Initial management consisted of irrigation and debridement, and application of the external fixator. In an attempt to obtain limb salvage, 92 additional procedures were performed to attain soft tissue coverage and insure bony stability. Six patients required subsequent below knee amputation at the level of the fracture site. All other cases achieved soft tissue coverage, bone union and are ambulatory on functional extremities without orthotic aids. Complications relating to the fixator included pin tract infections in eight patients and refracture in three.External fixation has application in limb salvage in severe extremity injuries associated with massive skin or muscle damage, neurovascular injuries and segmental bone loss. The advantages of the technique include rigid stabilization of the fracture and surrounding soft tissues, unencumbered wound access, motion of contiguous joints and simplified nursing care, indexing terms: External fixation, open extremity fractures, and musculoskeletal trauma.

Medical considerations in dance training for children.

Parents may consult family physicians about the safety of dance training for their children. Injuries in dance training are characteristically associated with improper technique, a poor training environment and fatigue. Many dance injuries can be prevented through attention to the physical and emotional maturity of the child, the quality of the instruction and the training environment. Quality dance training is safe and beneficial for children of any age.

Medical support for athletic events.

With the continued growth of individual and team sports competition, there has been an increasing demand for qualified medical coverage at athletic events. Clinicians who provide medical coverage at athletic events must be prepared to handle a variety of injuries and other emergencies. This report reviews the clinician's medical responsibilities in athletic coverage, and lists the supplies and equipment that should be included in a field kit for this use.

Neuralgic amyotrophy.

Neuralgic amyotrophy is an infrequent neuromuscular anomaly involving the shoulder girdle and upper extremity. Its course is highlighted by the sudden onset of severe pain followed by sensory deficits, muscle weakness, and severe atrophy. The diagnosis is based on the history and physical findings and is corroborated with electromyography. The prognosis is excellent. Treatment is supportive, using analgesics and physical therapy.

Wick catheter in evaluating and treating compartment syndromes.

We prospectively analyzed 45 patients with suspected compartment syndromes involving 55 extremities to determine the role of the wick catheter in their management. The wick catheter technic allows the continuous monitoring of interstitial pressure and provides an objective assessment of compartment pressure. Indications for catheter use, technics for catheter preparation and insertion, and guidelines for the timing of fasciotomy are presented. Clinical evaluation of every extremity injury must be tempered by suspicion and vigilance to detect compartment syndromes early enough to prevent ischemic contracture. Providing reliable and accurate pressure determinations without significant morbidity, the wick allows continuous monitoring of interstitial compartmental pressure and objective indications for fasciotomy.

Spine injuries associated with falls from hunting tree stands.

Spinal injuries resulting from falls out of tree stands are often associated with concomitant neurologic deficit, prolonged hospitalization, and long-term disability. The purpose of this study was to review the types of spinal injuries that resulted from falls from hunting tree stands. We retrospectively reviewed 27 patients who came to our institution for treatment of spine injuries related to tree-stand accidents between 1981 and 1997. Eleven percent of the falls were alcohol related. Mean height of the fall was 19.6 feet (range, 10 to 35 feet). There were 17 burst fractures, 8 wedge compression fractures, 4 fractures involving the posterior elements, and 1 coronal fracture of the sacral body. Significant neurologic injury occurred in 12 patients (44%). Sixteen patients (59%) had associated injuries. Nine patients (33%) had open reduction, internal fixation, and fusion of their spine fractures. One patient was treated with a halo jacket. The remaining patients were treated in rigid, molded, polypropylene thoracolumbar orthoses or lumbosacral corsets. Accidental falls from tree stands may result in significant spinal fractures often associated with concomitant neurologic injury, extended hospitalization, and permanent disability. Many of these injuries may be prevented through aggressive hunter safety education.

Renal intracortical blood flow during hemorrhage: role of adrenergic mechanisms.

Hemorrhagic hypotensin in anesthetized dogs produced a redistribution of renal blood flow from the outer to the inner cortex. The role of adrenergic mechanisms in this redistribution was studied in anesthetized dogs using a radioactive microspheres to determine intrarenal blood flow. Neither renal denervation, nor pretreatment with reserpine altered the characteristic redistribution of renal cortical flow during hemorrhage. These observations suggest that neither intact renal nerves nor circulating catecholamines are necessary for the redistribution of renal intracortical blood flow during hemorrhagic hypotension, and the role of myogenic autoregulation is emphasized.

Foot and ankle injuries in theatrical dancers.

The theatrical dancer is a unique combination of athlete and artist. The physical demands of dance class, rehearsal, and performance can lead to injury, particularly to the foot and ankle. Ankle sprains are the most common acute injury. Chronic injuries predominate and relate primarily to the repeated impact loading of the foot and ankle on the dance floor. Contributing factors include anatomic variation, improper technique, and fatigue. Early and aggressive conservative management is usually successful and surgery is rarely indicated. Orthotics play a limited but potentially useful role in treatment. Following treatment, a structured rehabilitation program is fundamental to the successful return to dance.

Evaluation of acute traumatic hemarthrosis of the knee joint.

Acute hemarthrosis of the knee usually results from a significant injury. Preoperative assessment, examination under anesthesia, and arthroscopic examination were conducted on patients with a total of 132 acutely injured knees associated with hemarthrosis and minimal clinical laxity to determine the presence and extent of injury to ligamentous and/or intra-articular structures. Partial or complete tear of the anterior cruciate ligament was found in 101 (77%) of the knees. Peripheral meniscal tears were responsible for the hemarthrosis in 17 cases (13%), and osteochondral fractures were found in 11 cases (8%). Injury to the anterior cruciate ligament was frequently associated with concomitant injury to other structures: meniscal tears (61%), ligament/capsular injury (40%), and hyaline chondral damage (16%). Patients' responses to preoperative anterior drawer, pivot shift, and Lachman tests were within normal limits in 18%, 29%, and 73% of cases, respectively. Patients under anesthesia responded to the anterior drawer and pivot shift tests normally 50% and 74% of the time. The Lachman test, performed under anesthesia, was 98% accurate in predicting anterior cruciate injury. Experience gained in evaluating posttraumatic hemarthrosis of the knee suggests clinical examination alone may not demonstrate the severity of many of these injuries. Arthroscopy, although not necessary to determine competence of the anterior cruciate ligament, is invaluable in determining the existence of other injuries with or without an associated anterior cruciate ligament tear.