Description of WALANT technique in open bone and ligament wrist surgery.

The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.

Anatomy and Correlation of the Coracoid Process and Coracoclavicular Ligament Based on Three-Dimensional Computed Tomography Reconstruction and Magnetic Resonance Imaging.

BACKGROUND The anatomy of the coracoid process and coracoclavicular (CC) ligament have been described and the correlation between them has been assessed based on 3-dimensional computed tomography (CT) reconstruction and magnetic resonance imaging (MRI), which provide a guide for coracoclavicular ligament reconstruction. MATERIAL AND METHODS Data were collected from 300 patients who underwent both CT and MRI of the shoulder joint from January 2017 to January 2019 at the Jiang'an Hospital of Traditional Chinese Medicine. The coracoid process was observed and classified and parameters of the CC ligament were measured according to different corneal types. All of the statistics were collected and classified by 2 radiologists, and average values were determined.Measurements of segments were taken as follows: ab - In the coronal plane, the length of the CC ligament from the central point of the CC ligament at the clavicular attachment to the CC ligament at the center of the CC attachment); ac - The distance from the center point of the CC ligament at the supraclavicular attachment to the acromioclavicular joint; de - In the sagittal plane, the length of the CC ligament from the center of the clavicular attachment to the coracoid attachment point; fg - The maximum diameter of the CC ligament at the anterior and posterior margins of the clavicle attachment; hi - The largest diameter of the CC ligament at the anterior and posterior edge of the coracoid process attachment; dj - The distance of the coracoclavicular ligament from the center point of the coracoid process attachment to the coracoid process tip; kl - The distance in the supraclavicular plane from the coracoclavicular ligament to the subcoracoid process. RESULTS The analysis showed that there are 5 types of coracoid process: gourd (31%), short rod (20%), long rod (22.3%), wedge (10.3%), and water drop (6.3%). There were statistically significant differences between the lengths of the ac and hi segments in the among the wedge and gourd-type and the short rod and water drop-type coracoid processes. There were statistically significant differences between the lengths of the ab, de, and fg segments in the short rod, gourd, and long rod-type coracoid processes. There were statistically significant differences between the lengths of the ac, fg, hi, dj, and kl segments in the water drop, gourd, and long rod-type coracoid processes. CONCLUSIONS The present study indicated that measurement of the CC ligament and the different shapes of the coracoid process provide an anatomical basis for the diagnosis and treatment of shoulder diseases and the data can be used to improve the safety of CC ligament reconstruction.

Sacrospinous Ligament Fixation Under Local Anesthesia in Elderly Patients at High Risk of General Anesthesia.

Introduction and Hypothesis: Sacrospinous ligament fixation(SSLF) is a commonly used surgical procedure in pelvic organ prolapse due to high treatment success rates. Many intraoperative and postoperative anesthesia-related obstacles may be encountered by the elderly population. Local anesthesia alone or with intravenous sedation may provide simple, cheap, and safe anesthesia. For elderly patients at high risk for general anesthesia according to the American Society of Anesthesiologists(ASA), it is better to operate through the vaginal route under local anesthesia. To perform minimal invasive SSLF surgery, the Pelvic Floor Repair Tissue Fixing Anchor, which is a target-specific system, can be used. In this prospective observational study, evaluation was made of elderly patients who underwent SSLF under local anesthesia. Materials and Methods: The study included 11 patients evaluated as high risk for general and regional anesthesia who underwent SSLF under local anesthesia as pelvic organ prolapse surgery. All operations were performed by a single experienced surgeon using 1% lidocaine infiltration and the Pelvic Floor Repair Tissue Fixing Anchor system. Results: The mean age of the patients was 69.6 years. Stage IV prolapse was determined in 7 (63.6%) patients, 4 (36.3%) had a history of hysterectomy, 5 (45.4%) were classified as ASA 3, and 6 (54.6%) as ASA 4. No complications occurred and patients were followed up for 24 months. In two patients, recurrence of POP was observed at postoperative 8 and 10 months, respectively. Conclusions: The results of this study demonstrated the surgical and anesthetic safety of SSLF under local anesthesia for pelvic organ prolapse in elderly patients.

Acute Scapholunate Ligament Injuries: Arthroscopic Treatment.

Wrist arthroscopy is an effective technique for treating acute scapholunate instability. It allows an accurate assessment of the degree and extent of the ligament injury. Partial injuries are effectively treated with arthroscopic debridement and electrothermal ligament tightening. Complete ligament injuries treated arthroscopically allow direct visualization of the torn ligament and assessment of the degree of scaphoid displacement and rotation. The use of arthroscopy allows a more accurate reduction of the scaphoid and lunate at the time of fixation than can be obtained using just fluoroscopy.

Long-term outcomes of arthroscopic debridement and thermal shrinkage for isolated partial intercarpal ligament tears.

A retrospective analysis was performed based on the medical records and imaging studies of 16 wrists (14 patients) with isolated partial intercarpal ligament tears (scapholunate ligament: 6 wrists, lunotriquetral ligament, 10 wrists) treated with arthroscopic debridement and thermal shrinkage. Three wrists had Geissler grade 1 tears and 13 wrists had grade 2 tears. Mean follow-up was 52.8 months. Overall pain visual analog scale scores improved significantly (P<.05) at rest and during activities of daily living and heavy manual work. Mean flexion-extension arc was 136.5°. Mean postoperative grip strength was 106 lb, which was significantly better than preoperative grip strength. Mean modified Mayo wrist score was 70 preoperatively and 94.7 postoperatively, a significant improvement. Overall functional outcomes according to the modified Mayo wrist score were rated as excellent in 13 wrists and good in 3. No patient had radiographic evidence of instability or arthritic changes. The scapholunate and lunotriquetral intervals in all patients were less than 3 mm on neutral and pronation grip radiographs. On lateral radiographs, no signs of intercalated segmental instability were seen, with a mean scapholunate angle of 55.3°. The results of this study suggest that arthroscopic debridement and thermal shrinkage provide symptomatic pain relief and prevention of intercarpal instability for a significant period of time in patients with partial intercarpal ligament tear.

Lunate and perilunate dislocations.

Lunate and perilunate dislocations are uncommon, but devastating carpal injuries, which, if unrecognized in the emergency department and not treated promptly, lead to a high incidence chronic wrist pain and long-term functional disability. In this case report, we will review the wrist joint anatomy as pertaining to these injuries, mechanism of injury, signs and symptoms, radiological findings, and treatment of such injuries.

Effect of homeopathy on analgesic intake following knee ligament reconstruction: a phase III monocentre randomized placebo controlled study.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: The efficacy of homeopathy is still under debate and a recent meta-analysis recommended further randomized double-blind clinical trials to identify any clinical situation in which homeopathy might be effective. WHAT THIS STUDY ADDS: The complex of homeopathy tested in this study (Arnica montana 5 CH, Bryonia alba 5 CH, Hypericum perforatum 5 CH and Ruta graveolens 3 DH) is not superior to placebo in reducing 24 h morphine consumption after knee ligament reconstruction. AIMS: The efficacy of homeopathy is still under debate. The objective of this study was to assess the efficacy of homeopathic treatment (Arnica montana 5 CH, Bryonia alba 5 CH, Hypericum perforatum 5 CH and Ruta graveolens 3 DH) on cumulated morphine intake delivered by PCA over 24 h after knee ligament reconstruction. METHODS: This was an add-on randomized controlled study with three parallel groups: a double-blind homeopathic or placebo arm and an open-label noninterventional control arm. Eligible patients were 18-60 years old candidates for surgery of the anterior cruciate ligament. Treatment was administered the evening before surgery and continued for 3 days. The primary end-point was cumulated morphine intake delivered by PCA during the first 24 h inferior or superior/equal to 10 mg day(-1). RESULTS: One hundred and fifty-eight patients were randomized (66 in the placebo arm, 67 in the homeopathic arm and 25 in the noninterventional group). There was no difference between the treated and the placebo group for primary end-point (mean (95% CI) 48% (35.8, 56.3), and 56% (43.7, 68.3), required less than 10 mg day(-1) of morphine in each group, respectively). The homeopathy treatment had no effect on morphine intake between 24 and 72 h or on the visual analogue pain scale, or on quality of life assessed by the SF-36 questionnaire. In addition, these parameters were not different in patients enrolled in the open-label noninterventional control arm. CONCLUSIONS: The complex of homeopathy tested in this study was not superior to placebo in reducing 24 h morphine consumption after knee ligament reconstruction.

[Arthroscopic dorsal ligament plasty using a hydrojet knife in the TMJ]. / Arthroskopische dorsale Kiefergelenkbandstraffung mit Wasserstrahlskalpell Eine experimentelle Studie am Landschwein.

PURPOSE: The aim of the study was the development and proof testing of an arthroscopic dorsal ligament plasty using a hydrojet knife in the pig TMJ before using in man. MATERIAL AND METHODS: The dorsal TMJ ligament of ten pigs (country breed) was irradiated with a hydrojet (diameter 120 microm, working pressure 90 bar) under arthroscopic visualization. Postoperatively the pigs were controlled for 10 weeks before sacrifice. The isolated TMJs were examined by light microscope and the results compared with untreated pig TMJs. The flows over our arthroscopic instruments were measured to exclude the possibility of damaging surrounding structures by pressure. RESULTS: Clinically we found no complications after arthroscopic surgery. Food intake was normal and development of body weight according to the food offered. Histology revealed tissue reorganization connected with increased collagen fibre production. Our calculations showed no pressure higher than 1000 mm water column in the TMJ under our working conditions. CONCLUSIONS: The idea of arthroscopic dorsal ligament plasty using a hydrojet works in pig TMJs. Experience in TMJ arthroscopy is necessary. We found no danger of barotrauma under arthroscopy with the hydrojet. The results indicate dorsal ligament shortening by development of scar formations. In our opinion the method can be used for the therapy of dorsal ligament elongation and disk displacements in the TMJ of man.

[Surgical treatment of rupture of the coracoclavicular ligament and postoperative rehabilitation]. / Operacijsko lijecenje rupture korakoklavikularnog ligamenta i poslijeoperacijska rehabilitacija.

The aim of this paper is to present the results of the operative treatment of the coracoclavicular ligament. According to Tossy, the injuries are classified into thre degrees. Younger patients and sportsmen (57) with the injury of the third degree were operated in the period from 1987-2000. The diagnostic methods were clinical examination and x-ray in the frontal and sagital plane. The patients were operated by Bosworth method. The operation technique which is described is slightly modified as it facilitates the surgeon's work and gives excellent post-operative results. The immobilisation was not used in the post-operative treatment. During the first week after operation a patient does static isometric exercises using the muscles of shoulders and arms, breathing exercises and passive exercises of the arm up to pain limit. The screw was removed under the local anesthesia after minimum of 6 weeks. Upon the removal of the osteosynthetic material we applied kynetic, hydro, magnetic and electrotherapy. The results of the operation were estimated after 2.5 months. Taking into consideration the functions of coracoclavicular ligament (the regulation of angle between clavicle and shoulder-blade, the limitation of rotation and elevation of clavicle, the support in bearing arm weight, the relaxation of joint between clavicle and shoulder-blade and the lateral reinforcement of acromioclavicular joint) its complete reconstruction is very important, and with the appropriate fixation of clavicle and shoulder-blade, accompanied by physical therapy, makes the basis for good results after the operation.

Efficacy of oral calcium pentosan polysulphate for the treatment of osteoarthritis of the canine stifle joint secondary to cranial cruciate ligament deficiency.

The efficacy of calcium pentosan polysulphate (CaPPS) as a slow-acting drug for the treatment of osteoarthritis of the canine stifle joint, secondary to cranial cruciate ligament deficiency, was tested in a double-blind, placebo-controlled clinical trial over a period of one year. Dogs with the deficiency were treated surgically, matched for bodyweight, and randomly assigned to treatment or placebo groups. Active treatment began six weeks postoperatively and consisted of 10 mg/kg CaPPS orally, once weekly for four weeks, repeated every 12 weeks. The outcome was assessed in terms of function by the dogs' owners, by the radiographical grading of the osteoarthritis, and by the measurement of total sulphated glycosaminoglycans and the 5D4 epitope of keratan sulphate in the synovial fluids of affected joints. There were no differences either in functional outcome or in the radiographical progression of osteoarthritis between the two groups. Fifty-four weeks after surgery, the concentration of 5D4 in synovial fluid (expressed as change from baseline values) had decreased significantly in the treatment group compared with the placebo group (P=0.03).

Knee arthroscopy in local versus general anaesthesia. The incidence of rearthroscopy.

The choice of anaesthesia in routine knee arthroscopy varies considerably. Concerns about local anaesthesia include the fear that it will take longer to perform surgery and that the anaesthesia will be inadequate, leading to patient discomfort. In this study, data from all patients (n = 6519) who had undergone a knee arthroscopy at St Göran Hospital Artro Clinic, in Stockholm, Sweden, during a 3.5 year period, between January 1993 and July 1996, were reviewed. Of these 6519 primary arthroscopies, 4101 were performed under local anaesthesia and 2418 under general anaesthesia. The purpose of the study was first to identify those arthroscopies that could not be successfully performed because the local anaesthesia was inadequate, and second, to investigate if arthroscopy under local anesthesia was associated with an increased number of rearthroscopies compared to general anaesthesia. The total number of rearthroscopies, performed within 180 days from the primary arthroscopy, was 214. Of these 214 rearthroscopies, 146 were due to a new indication for surgery and 30 were due to persisting clinical symptoms (true rearthroscopies). The remaining 38 rearthroscopies were due to an incomplete examination (because of patient discomfort) in a primary procedure where local anaesthesia was used. Of the 30 true rearthroscopies, 19 originated from the 4101 primary arthroscopies performed under local anaesthesia (0.46%) and 11 originated from the 2418 primary arthroscopies performed under general anaesthesia (0.45%). It is concluded that 0.9% of the primary arthroscopies performed under local anaesthesia could not be performed safely due to patient discomfort. There was no difference in the frequency of rearthroscopy between the arthroscopies performed under local anaesthesia compared to those performed under general anaesthesia.

[Results of arthroscopic ventral limbus capsule refixation after primary traumatic shoulder dislocation]. / Ergebnisse nach arthroskopischer ventraler Limbus-Kapsel-Refixation nach primärer traumatischer Schulterluxation.

The three-year results for arthroscopic refixation of the labrum-ligament-capsule complex after traumatic primary dislocation of the shoulder will be discussed. This prospective study included only patients with primary dislocations showing radiographic signs of anterior instability in the drawer test and no accompanying bony injuries. Twenty-six patients with an average age of 31 years and arthroscopic suture had been dismissed from postoperative treatment after an average 15 weeks showing a fully mobile and pain-free shoulder joint. At the time of follow-up the average results obtained with our own score were 94.1 points. 61.5% of the patients showed fully mobile shoulder joints and 84.6% reported full sporting capacity. Negative findings were obtained for all stability tests performed after 32 months. No recurrencies had occurred until the time of the follow-up. Compared to the reluxation rates described in the literature for traumatic primary shoulder dislocations in juvenile patients, our three-year results were highly positive and we will continue to use arthroscopy in the treatment of instable shoulder joints after traumatic primary dislocation in order to avoid recurrencies and associated sequelae.

Coracoacromial ligament release for shoulder impingement syndrome using the Universal Subcutaneous Endoscope system.

We developed a new operative procedure of coracoacromial ligament release for shoulder impingement syndrome. The operative procedure was confirmed by cadaveric studies and applied to clinical cases in 40 shoulders of 37 patients who suffered from shoulder impingement without bony abnormalities. The subacromial space was observed under local anesthesia using the Universal Subcutaneous Endoscope (USE) system on an outpatient basis. A popping phenomenon was observed between the coracoacromial ligament and the greater tuberosity of the humerus, which was covered by the rotator cuff, and the coracoacromial ligament was resected with a rongeur under endoscopic visualization in all shoulders. Resection of the coracoacromial ligament relieved the impingement and clinical signs, as in open or arthroscopic resection of the coracoacromial ligament. Resection of the coracoacromial ligament using the USE system is a safe and less-stressful surgical invasion than open or standard arthroscopic resection of the coracoacromial ligament.

Electromyographic biofeedback and recovery of quadriceps femoris muscle function following anterior cruciate ligament reconstruction.

The purpose of this study was to compare the effects of biofeedback-facilitated exercise with exercise alone on the recovery rate of quadriceps femoris muscle function following anterior cruciate ligament (ACL) reconstruction. Functional measures included 1) a dynamometric test of quadriceps femoris muscle isometric peak torque during the 12th postoperative week and 2) the number of days post-operatively that a patient achieved full active extension of the knee. Twenty-two patients with acute ACL injury were randomly assigned to a Treatment (biofeedback) Group (n = 11) or a Control (nonfeedback) Group (n = 11) during the first therapy session one week after reconstructive surgery. After the patients had completed the 12-week exercise program, the quadriceps femoris muscle isometric peak torque in the operative limb was compared with that in the nonoperative limb at three angles (90 degrees, 60 degrees, and 45 degrees) of extension. An analysis of variance revealed significant differences between the Treatment and Control Groups at all three angles. Mean recovery time was calculated for each group, and a t test for independent samples indicated a significant difference between the groups. These results demonstrate that the addition of biofeedback to muscle strengthening exercises facilitates the rate of recovery of quadriceps femoris muscle function following ACL reconstruction.

[Surgical therapy of fibular capsule-ligament rupture]. / Operative Therapie der fibularen Kapselbandruptur.

Different procedures for primary reconstruction of ruptured ligaments in fresh lateral ankle ligament injuries are reported. Selective local anesthsia of the nervus fibularis superficialis and suralis is considered a protective and low-risk method. In our opinion the primary surgical treatment of lateral ankle ligament ruptures is still the most adequate treatment, especially in sportsman.

Electrical stimulation versus voluntary exercise in strengthening thigh musculature after anterior cruciate ligament surgery.

Twenty patients who had undergone anterior cruciate ligament reconstructive surgery were placed randomly and independently in an Electrical Stimulation Group (n = 10) or Voluntary Exercise Group (n = 10) to compare the effectiveness of these two muscle-strengthening protocols. Patients in both groups used simultaneous contraction of quadriceps femoris and hamstring muscles during a training regimen that consisted of either voluntary exercise or electrical stimulation trials five days a week for a three-week period within the first six postoperative weeks. After patients completed the training regimen, bilateral maximal isometric measurements of gravity-corrected knee extension and flexion torque were obtained for both groups and percentages were calculated. Results showed that patients in the Electrical Stimulation Group finished the three-week training regimen with higher percentages of both extension and flexion torque when compared with patients in the Voluntary Exercise Group (extension: t = 4.35, p less than .05; flexion; t = 6.64, p less than .05). These results indicate that patients in an electrical stimulation regimen can achieve higher individual thigh musculature strength gains than patients in a voluntary exercise regimen when simultaneous contraction of thigh muscles is prescribed during an early phase of postoperative rehabilitation.

Effects of electrical muscle stimulation combined with voluntary contractions after knee ligament surgery.

The aim of the present study is to compare the effect of electrical muscle stimulation combined with voluntary muscle contractions with a program only with voluntary muscle contractions during immobilization in casts after anterior cruciate ligament surgery. Twenty-three patients, 7 women and 16 men with a mean age of 28 yr, were randomized into two groups: an experimental group (13 patients) and a control group (10 patients). Post-operatively, the patients were immobilized for 3 wk in a full leg cast with the knee flexed at an angle of 20 degrees to 30 degrees and then in a knee cast for another 3 wk. All patients had a standard program with quadriceps muscle contractions. In addition, the experimental group received electrical stimulation of the quadriceps muscle 4 X 10 min, 3 times.wk-1, at a frequency of 30 Hz. During each stimulation, the patients were requested to contract the quadriceps muscle voluntarily as well. When pre-operative measurements were compared with those at the end of the immobilization period (6 wk after the operation), a significantly larger reduction in the knee extension isometric muscle strength was found for the control group than for the experimental group. In comparisons of the data of the male subjects only, this difference was still seen to be significant. The cross-sectional area of the quadriceps muscle measured with computed tomography was significantly less reduced during the immobilization period in the experimental group than in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Electrically elicited co-contraction of thigh musculature after anterior cruciate ligament surgery. A description and single-case experiment.

The purpose of this article is to describe a method for strengthening the quadriceps femoris muscle in a patient after anterior cruciate ligament (ACL) surgery. The method incorporates electrically elicited co-contraction of the quadriceps femoris and hamstring muscles. A single-case experimental design based on a split-middle (ABAB) technique was used to assess the effects of the systematic administration and withdrawal of electrical stimulation with respect to changes in knee isometric extension and flexion torque and circumferential measurements of the thigh in a patient six weeks after ACL reconstruction. Results show increases in extension and flexion torque and thigh circumferential measurements that are associated with both stimulation (treatment) phases in addition to a maintenance effect demonstrated during the withdrawal phase. In this patient, the technique appears to be effective in increasing muscle strength and circumferential measurements, particularly quadriceps femoris muscle torque. Implications and suggestions for future research are included.

[Initial experiences with ambulatory ligament suture of the fresh ligament rupture of the upper ankle joint using local anesthesia]. / Erste Erfahrungen mit der ambulanten Bandnaht der frischen lateralen Bandruptur am oberen Sprunggelenk in Lokalanästhesie.

Reported in this paper is preliminary experience obtained from outpatient suturing in local anaesthesia of recent rupture of fibular ligaments. An indication of this kind is valid for all cases of established rupture of ligaments, with due consideration to be given to individual factors. The method is extensively described. Preliminary short-time results so far recorded from 18 outpatient cases of ligament suturing in local anaesthesia appear to underscore this therapeutic approach as optional in acute situations. Reference is made to early functional therapy to avoid immobilisation damage, and a therapeutic concept is proposed.