Outcome of osteochondral autograft transplantation for type-V cystic osteochondral lesions of the talus.

The treatment of osteochondral lesions of the talus has evolved with the development of improved imaging and arthroscopic techniques. However, the outcome of treatment for large cystic type-V lesions is poor, using conventional grafting, debridement or microfracture techniques. This retrospective study examined the outcomes of 50 patients with a cystic talar defect who were treated with arthroscopically harvested, cored osteochondral graft taken from the ipsilateral knee. Of the 50 patients, 45 (90%) had a mean good to excellent score of 80.3 (52 to 90) in the Karlsson-Peterson Ankle Score, at a mean follow-up of 36 months (24 to 83). A malleolar osteotomy for exposure was needed in 26 patients and there were no malleolar mal- or nonunions. One patient had symptoms at the donor site three months after surgery; these resolved after arthroscopic release of scar tissue. This technique is demanding with or without a malleolar osteotomy, but if properly performed has a high likelihood of success.

Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts.

Treatment of symptomatic large cystic lesions of the talus has had mixed results. A technique of treatment using a cored osteochondral graft taken from the ipsilateral knee is presented. Preliminary results in ten consecutive patients show significant improvement in all patients with an average increase of 27 points in the AOFAS Hindfoot score.

Management of knee pain and stiffness after total knee arthroplasty.

This article reviews 33 patients who presented with persistent pain, inadequate knee motion, or both after total knee arthroplasty. Of 33 patients, 26 had inadequate motion treated by closed manipulation, arthroscopic manipulation, or a modified open release manipulation. In 23 patients, these procedures were successful. Of the 26 patients, 85% had a history of previous knee surgery or diabetes mellitus. The average gain in range of motion was not different in comparing early (<12 weeks) manipulation versus late (>12 weeks) manipulation. Seven of the 33 patients presenting with pain, swelling, inadequate motion, or snapping sensations had either failure of bonding between the polymethyl methacrylate and the components (4 patients) or painful fibrous intra-articular bands (3 patients). These patients were treated successfully either by recementing the components or by arthroscopic fibrous band release.

The relationship between chronic ankle instability and variations in mortise anatomy and impingement spurs.

Thirty-five patients undergoing a Bröstrom procedure for ankle instability were studied retrospectively as to the presence or absence of spurs and loose bodies, outcome, and mortise relationships. 100 adult volunteers had their ankles radiographically and clinically examined for spurs, loose bodies, and laxity. 100 patients' ankles with computed axial tomography were examined to define malleolar relationships. The AOFAS Hindfoot scores on the Bröstrom patients with or without spurs were not different. Patients undergoing a Bröstrom procedure had a 3.37 times incidence of spurs and/or loose bodies compared to normal adult population. The incidence of asymmetric but asymptomatic ankle laxity in normal adults was 11%. The fibula has a 38 degree range of position relative to the axis of the talus and the medial malleolus. A posterior fibular position may predispose to injury.

Role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18-351 months). All patients' feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.

Comparison of open isolated subtalar arthrodesis with autogenous bone graft versus outpatient arthroscopic subtalar arthrodesis using injectable bone morphogenic protein-enhanced graft.

Isolated subtalar joint arthrodesis is an established salvage procedure that can be performed in various ways for varying diagnoses. The purpose of this article is to report a new arthroscopic subtalar arthrodesis technique that has been developed. The results of this method versus an open technique were compared. Length of hospital stay, tourniquet time, morbidity, and fusion rate were studied in 17 fusion patients between 1990 and 1997. Twelve patients had open arthrodesis with bone graft and 5 patients had arthroscopic arthrodesis with supplemental, injectable, osteoinductive enhanced-graft gel. The length of stay decreased 1.7 days with the arthroscopic procedure. Tourniquet time was not significantly different. One open procedure required refusion, whereas none did in the arthroscopic group. One patient in each group required AO screw removal. In selected patients with subtalar arthrosis without significant hindfoot deformity, arthroscopic arthrodesis can be an effective. It is too early to determine if there are specific advantages in this procedure compared with a conventional open arthrodesis.

The cost effectiveness of streamlined care pathways and product standardization in total knee arthroplasty.

The orthopaedic department at Providence Medical Center, Seattle, Washington, instituted a streamlined care pathway and product standardization for total knee arthroplasty (TKA) in July 1995. The goal was to reduce operating room time and to streamline the care pathway for a safe, expedited hospitalization of patients. The hospital staffs standardized nursing orders, cut the instrument systems from 13 to 4 sets, and coordinated the expedited care pathway. Fifty-two consecutive primary TKAs were compared prepathway to 77 consecutive primary TKAs postpathway. The average length of stay declined 1.9 days from 5.1 to 3.2. The tourniquet time declined from 61 minutes to 56 minutes. The average dollar charges were $1,063 less. There were no infections in either group. The manipulation rate for adhesions declined 37%.

Mechanisms of anterior cruciate ligament neovascularization and ligamentization.

Columbia-Rambouillet cross-bred sheep were used to study the revascularization and ligamentization process of anterior cruciate ligament (ACL) reconstruction over a 6-month period using basic histology, immunohistochemistry, and electron microscopy. The reconstruction technique studied was a quadruple-hamstring, interference screw fixation technique. Further, these specimens, after retrieval at 6, 12, and 26 weeks, were compared with human arthroscopic 'second looks' and with 10 en bloc specimens obtained when a cruciate-sacrificing total knee replacement was performed. The study showed that, with this reconstruction technique, Sharpey's fibers were seen at 6 weeks in both sheep and human specimens. The intratunnel specimens showed proliferative chondrification, then ossification of the matrix. Intra-articular neovascularization, ligamentization, and junction ossification occurred. Myoblasts or smooth muscle cells appear to mediate the ligamentization as evidenced in electron microscopy by proliferate collagen manufacture. These myoblasts were seen in both the healing sheep and human second looks, but not seen in mature ACL grafts or in normal ACLs. At 6 months postoperatively, the sheep ACL reconstruction appeared clinically, histologically, and immunohistochemically indistinguishable from the normal sheep ACL. A correlation of this work with published animal studies in which biomechanical testing was performed and with human 'second looks' would imply that an ACL reconstruction may be vulnerable during this period of neovascularization and ligamentization.

Chronic disorders of the Achilles tendon: results of conservative and surgical treatments.

We reviewed our results of nonoperative and operative treatment of chronic Achilles tenosynovitis to further define outcomes and treatment parameters. Forty-one patients presented with an average of 14 weeks of Achilles tendon symptoms. All patients received nonsurgical treatment initially, and 21 patients (51%) recovered after an average of 18 weeks of therapy. Three additional patients improved after brisement of the tendon/peritenon interspace. Seventeen of 41 patients eventually underwent soft tissue tenolysis and/or excision of degenerative tendon cysts. Those patients who responded to nonoperative therapy tended to be younger (average age, 33 years) than those who had degenerative tendon changes requiring surgery (average age, 48 years). All surgical patients were able to return to unrestricted activity after 31 weeks (range, 27-48 weeks). We believe 4 to 6 months of nonsurgical therapy is appropriate for middle aged patients or athletes with chronic Achilles tenosynovitis. Those that fail this treatment will improve with a limited debridement of diseased tissue without excessive soft tissue dissection of the tendon.

Pathologic anatomic variations in subtalar anatomy.

Thirteen patients presenting with symptomatic pathologic variations or congenital deformities of the subtalar joint are presented. These variations included: four abnormal posterior talar processes, five patients with asymmetric subtalar joint development, and four congenital complete subtalar coalitions with a secondary ball-and-socket joint. In each case these adult patients had been unaware of the variation and had been symptom free until "awakening" sprain or fracture trauma brought about symptoms. The nonoperative and operative management of these variations is reviewed.

Outpatient endoscopic quadruple hamstring ACL reconstruction.

When a surgical reconstruction is necessary for a patient with an anterior cruciate ligament (ACL) injury, autologus tissue from either a bone-patellar tendon-bone or hamstring tendon grafts is preferable. There are relative and absolute contraindications for the use of either tissue, in addition to the surgeon's own preference. For example, a patient with Erlos-Danlos ligamentous laxity is not a candidate for a hamstring ACL reconstruction.

A review of selected noncontact anterior cruciate ligament injuries in the National Football League.

During five football seasons, from 1989 through 1993, 61 surgically proven, noncontact, anterior cruciate ligament injuries, were identified from among 22 National Football League teams. The variables of surface, shoe type, playing conditions, and whether or not the shoe was spatted were identified for each reported injury. Forty noncontact injuries occurred in conventional cleated shoes on natural grass, and 21 occurred on an artificial surface. Almost half of all injuries (47.5%) occurred during game-day exposures despite the fact that the practice versus game-day exposure rate was 5:1. Of these injuries, 95.2% (N = 58) occurred on a dry field. The factors of cleat and shoe type, type of surface (natural versus artificial), surface conditions (wet/dry), and the effect of "spatting" a shoe are presented. The significance of these factors and their likelihood to be associated with injury is analyzed by use of a statistical tool, the incidence density ratio.

Differences in friction and torsional resistance in athletic shoe-turf surface interfaces.

This study evaluated the shoe-surface interaction of 15 football shoes made by 3 manufacturers in both anterior translation and rotation using a specially designed pneumatic testing system. The shoes included traditional cleated football shoes, "court" shoes (basketball-style shoes), molded-cleat shoes, and turf shoes. Under an 11.35-kg (25-pound) axial load, all shoes were tested on synthetic turf under wet and dry conditions and on natural stadium grass. Test-retest reliability, as calculated using the Pearson Product-Moment Correlation test, was 0.85 for force of translation and 0.55 for the moment of rotation. The wet versus dry surface values on translation were significantly different for rotation about the tibial axis. Spatting, which is protective taping of the ankle and heel applied on the outside of the shoe, resulted in a reduction of forces generated in both translation and rotation. No overall difference between shoes on grass versus AstroTurf was noted. However, there were significant differences for cleated and turf shoes. Shoes tested in conditions for which they were not designed exhibited reproducible excessive or extreme minimal friction characteristics that may have safety implications. On the basis of this study, we urge shoe manufacturers to display suggested indications and playing surface conditions for which their shoes are recommended.

Prognostic factors in bunion surgery.

Between 1977 and 1992, 42 patients were seen who had 51 feet operated upon for bunions in which the surgery failed. A total of 105 procedures were done on these 51 feet until the patients either achieved satisfactory correction (N = 28) or they declined (N = 14) further surgery. An analysis of these failures and review of literature revealed 12 anatomic variations and 7 secondary factors that were seen in association with surgical failure. These findings were correlated with published criteria and our experience with various bunion procedures to advance general indications and contraindications for specific bunion procedures.

Mucoid degeneration of the patellar ligament in athletes.

Seven post-traumatic mucoid cysts of the patellar ligament occurred in six athletes. Non-operative treatment of two of the seven cysts was successful, as was operative resection of the remaining five cysts. The lesion, while uncommon, must be considered in the differential diagnosis for athletes who have persistent pain in the knee.

Anterior tibiotalar spurs: a comparison of open versus arthroscopic debridement.

We compared the difference in operative time, hospitalization and recovery time in two groups of patients who underwent open or arthroscopic resection of anterior, tibiotalar, impinging spurs. The operative time was approximately the same, but the average length of hospitalization and time to recovery were shorter in the arthroscopic group. A classification system is proposed that grades the degree of spur formation and assists in predicting the length of recovery time and whether the patient is a candidate for open or arthroscopic spur resection. In this series, grade I spur patients recovered and resumed full activity at 5.0 weeks, grade II at 5.6 weeks, grade III at 6.4 weeks, and grade IV at 10.0 weeks postoperatively. Grade IV patients are not suitable candidates for an arthroscopic debridement.

Results of arthrodesis of the tarsus: talocalcaneal, midtarsal, and subtalar joints.

A 10-year prospective study was carried out on arthrodesis surgery of the major tarsal joints of the foot. The guiding principle of the study was that foot symmetry would be preserved, except where both feet were deformed. Correction in the frontal, coronal, and sagittal planes would be used to restore normal talocalcaneal relationships. In patients with normal relationships, triple, subtalar (talocalcaneal), and isolated tarsal arthrodesis would be carried out by iliac-crest-inlay grafting to preserve tarsal relationships. In 41 patients, 47 arthrodeses were carried out. There were 31 triple arthrodeses, 10 talocalcaneal fusions, four talonavicular fusions, and two naviculocuneiform fusions. In patients with deformity, significant improvement in the angles of anteroposterior talocalcaneal divergence and lateral talocalcaneal convergence was recorded. There were 27 good results, 15 fair results, and five poor results. Supplementary bone grafting and the use of internal fixation improved the rate of arthrodesis.

An overview of ankle arthrodesis.

Arthrodesis of the ankle can result in a painless, normal walking gait. However, complications in ankle arthrodesis can be major, and can occur when anatomy, deformity, or bony deficiency is not properly addressed. Nonoperative treatment should always be considered first, and, if possible, an open or arthroscopic ankle debridement can provide significant pain relief. Arthrodesis should be considered after conservative treatment fails. Infections, deformity, sensory deficiencies, and bony defects require special consideration. The use of bone graft and internal or external compression will enhance the likelihood of a successful arthrodesis.

Combined reconstruction of the anterior cruciate ligament in competitive athletes.

Fifty-eight professional and competitive amateur athletes had a combined reconstruction of the anterior cruciate ligament, with use of the semitendinosus tendon for the intra-articular portion of the reconstruction and a strip of iliotibial band for the extra-articular augmentation. Thirty patients (thirty-two knees) were evaluated two to seven years postoperatively to assess the results and the ability to return to athletics. Follow-up consisted of an interview, clinical and roentgenographic examinations, and testing with an arthrometer. Six patients (20 per cent) had a rating of excellent; twenty-two (73 per cent), good; and two (7 per cent), fair. There were no poor results. Of the thirty-two knees, twenty had an associated injury: twenty meniscal tears in eighteen knees, three tears of the medial collateral ligament, four osteochondral fractures of the lateral femoral condyle, and two loose bodies. Combined reconstruction of the anterior cruciate ligament resulted in improved stability of the knee in these patients whose goal of treatment was to be able to resume sports at a highly competitive level.