Risk factors for restricted motion after anterior cruciate reconstruction.

A retrospective review of 373 patients who had undergone anterior cruciate ligament (ACL) reconstruction utilizing the central third of the patellar tendon was undertaken to identify those factors that placed a patient at risk for restricted postoperative motion (flexion < or = 125 degrees or flexion contracture > or = 10 degrees). Stepwise logistic regression analysis determined that the variables most strongly correlated with restricted final range of motion (ROM) were open surgery (P = .0008) and reconstruction performed < or = 7 days after the initial injury (P = .004). Age, associated meniscal repair, or associated collateral ligament injuries did not significantly affect the ROM. A subgroup of 204 patients arthroscopically reconstructed more than 7 days post-injury were significantly less likely to have limited motion when ROM exercises were begun within 2 days of surgery (P = .008). These data support delayed, arthroscopic ACL reconstruction followed by early ROM exercises as useful techniques for avoiding postoperative motion problems.

Dislocation and fracture-dislocation of the carpometacarpal joints.

Dislocations and fracture-dislocations of the carpometacarpal joints are rare. Diagnosis requires a high index of suspicion, careful examination, and appropriate radiography. Treatment is controversial and is based upon the injury pattern and the surgeon's experience and preference. This article reviews the pertinent anatomy, mechanism of injury, evaluation, and treatment of patients with carpometacarpal joint injuries.

Biomechanical analysis of mallet finger fracture fixation techniques.

A biomechanical study was conducted to determine the best fixation technique for mallet finger fracture among four commonly used methods. Considerations were technical complications, biomechanical properties, and maintenance of reduction. Techniques tested included Kirshner wire, figure-of-eight wire, tension band wire, and tension band suture. Technical complications were frequent with both the Kirschner wire and tension band wire techniques. Biomechanical testing yielded significantly greater energy absorbed to failure and a trend toward greater peak loads to failure for both the figure-of-eight wire and tension band suture techniques. Irreversible loss of reduction during testing occurred in all of the Kirschner wire-fixed fractures, in 60% of the tension band wire-fixed fractures, and in 50% of the figure-of-eight wire-fixed fractures. No irreversible failure occurred in the tension band suture group.

Anterior cruciate ligament reconstruction. The effect of tibial tunnel placement on range of motion.

In 111 patients who had anterior cruciate ligament reconstructions, postoperative radiographic measurements of anterior to posterior and medial to lateral location of the tibial tunnels were correlated with the final range of motion achieved. In the 25 patients with extension deficits of 10 degrees or more, placement of the tibial tunnel was more anterior (average, anterior 23% of the tibia) than in the remaining 86 patients with extension deficits of < 10 degrees (average, anterior 29% of tibia). This difference was statistically significant with P < 0.001. Logistic regression analysis revealed that the more anterior the placement of the tibial tunnel, the greater the loss of both flexion (P = 0.01) and extension (P = 0.002). In the 21 patients with full extension but flexion < 130 degrees, placement of the tibial tunnel tended to be more medial (average, medial 40% of the tibia) than in the 65 patients without flexion deficit (average, medial 45% of the tibia). We conclude that placement of the tibial tunnel in the "eccentric," anteromedial position may contribute to the development of flexion and extension deficits after anterior cruciate ligament reconstruction.

Traumatic lateral scapular displacement: an expanded spectrum of associated neurovascular injury.

The clinical entity of "scapulothoracic dissociation" has been reported as an uncommon but devastating shoulder girdle disruption. All previously identified closed injuries have been associated with arterial and brachial plexus compromise; therefore, neurovascular disruption has been presented as an essential diagnostic clinical finding of scapulothoracic dissociation. We have identified and managed four patients who satisfy all the radiographic criteria for scapulothoracic dissociation but who have presented with a spectrum of neurovascular conditions ranging from entirely normal to complete disruption. These patients illustrate a previously unrecognized, or at least unreported, continuum of potential neurovascular compromise associated with disruption of the scapulothoracic articulation. An expanded and more descriptive classification scheme for "traumatic lateral scapular displacement" is proposed to emphasize the spectrum of possible presentations of this injury.

Anterior cruciate ligament tears in skeletally immature patients: meniscal pathology at presentation and after attempted conservative treatment.

We evaluated 12 skeletally immature patients with acute, intrasubstance tears of the anterior cruciate ligament (ACL) and open physes for meniscal pathology. Arthrograms were completed in 10 of 12 patients, and subsequent arthroscopy confirmed 8 meniscal tears (4 medial, 4 lateral) in 6 patients. Four patients with repairable menisci underwent arthroscopic meniscal repair and stabilization. Eight patients received quadriceps and hamstrings rehabilitation and returned to sports with a brace. After return to sports, all braced patients developed instability with multiple episodes of "giving way." Average time from initial injury to first episode of instability was 7 months. Seven patients sustained further meniscal damage an average of 15 months (range 7-27 months) after initial injury. We conclude that meniscal pathology is commonly associated with ACL tears in skeletally immature patients and we recommend arthrography or arthroscopy to evaluate patients with suspected ACL tears. Brace management did not prevent instability or new meniscal tears.

Results of knee manipulations after anterior cruciate ligament reconstructions.

We analyzed the results of knee manipulations in 42 knees that had persistent flexion or extension deficits after intraarticular ACL reconstructions. All manipulations were done under a spinal or general anesthetic and, in 10 cases, arthroscopic debridement of adhesions also was performed. The average time from reconstruction to manipulation was 7 months (range, 3 to 14 months) and the average followup was 26 months (range, 6 to 56 months). At manipulation, average flexion was increased from 95 degrees to 136 degrees and average extension from 11 degrees to 3 degrees. In no case was motion gained at the expense of joint stability and, at final followup, average flexion and extension were 127 degrees and 4 degrees, respectively. The final range of motion achieved was not affected by the time to manipulation, severity of premanipulation flexion deficit, or concomitant arthroscopic debridement of adhesions. However, knees with premanipulation extension deficits of greater than or equal to 15 degrees achieved significantly less final extension than knees with lesser premanipulation deficits. Overall, manipulations were a safe and effective method for improving both flexion and extension in 86% of the knees that had restricted motion after ACL reconstructions.

Osteochondritis dissecans of the knee: value of MR imaging in determining lesion stability and the presence of articular cartilage defects.

Osteochondritis dissecans is a lesion of articular surfaces that is of uncertain etiology. These lesions are seen on radiographs as a bony defect or fragmentation of the subchondral bone. A bony defect may be an actual surface hole or the defect may be filled with fibrous tissue or fibrocartilage. Similarly, the apparent bone fragments may be only partially attached so they are unstable and prone to displacement or they may be firmly attached with fibrous tissue. Knowledge of fragment stability and the presence of an articular cartilage defect is useful in deciding on treatment. This information cannot be determined on plain films or clinical examination. We correlated MR examinations with arthroscopic findings in 21 patients with osteochondritis dissecans of the knee to see if MR imaging could be used to predict lesion stability and articular cartilage defects. A high-signal interface between the lesion and the femur was used as evidence of lesion instability and was found in 15 lesions. One of these lesions was questionably stable at surgery; the remainder were unstable and partially attached. The other six patients had displaced fragments with large articular defects that were clearly visualized on the MR examinations. We conclude that MR imaging is useful in evaluating articular surface defects and lesion stability in patients with osteochondritis dissecans.

Value of MR imaging in staging osteochondral lesions of the talus (osteochondritis dissecans): results in 14 patients.

Osteochondral lesions (osteochondritis dissecans) of the talus are common articular lesions that are usually traumatic in origin. Clinical management of these lesions is based on whether or not the fragments are attached. We studied the value of MR imaging in determining the stability of the osteochondral fragments. In 13 of 14 patients who had had correlative surgery, we accurately predicted the presence and extent of attachment of the fragment to the talus by performing preoperative MR imaging. The other patient had a false-positive diagnosis of a chondral fragment. All seven partially attached fragments had an irregular high-signal zone on T2-weighted images at the fragment/talar interface. The four unattached fragments had a complete ring of fluid surrounding the lesion. On the basis of these findings, we think MR of the ankle can be used to assess accurately talar osteochondral lesion stability and aid in clinical decision making.

Biomechanical and histological evaluation of the Herbert screw.

The Herbert screw has been demonstrated to have widespread clinical applicability. A biomechanical and histological evaluation of the Herbert screw was conducted to better define its applications. When subjected to pull-out, toggle, and compression testing, in a cancellous bone calf model, it was demonstrated to be biomechanically inferior to the 4.0 mm ASIF cancellous screw. The use of two Herbert screws minimized but did not eliminate this difference. Articular cartilage healing in a rabbit model was consistently demonstrated if the Herbert screw was buried deep to the osteochondral junction. However, toluidine blue histochemical staining showed that the hyaline-like repair cartilage differed qualitatively from normal cartilage. Utilization of the Herbert screw should include an understanding of the limitations of its fixation potential and a recognition of the repair response after intraarticular applications.

Results in patients with craniocerebral trauma and an operatively managed acetabular fracture.

Results in 23 patients with significant craniocerebral trauma (Glasgow Coma Scale less than or equal to 10) and displaced acetabular fracture requiring surgery were reviewed after a minimum follow-up of 1 year. Despite a postoperative anatomic reduction in all but one case, clinical outcome for these hips was poor, with an average Harris hip rating of 59. Patients older than 40 years had a significantly poorer outcome than did younger patients (p = 0.004). Postoperative problems occurred in 70% of patients (n = 16); the largest portion of these represented symptomatic heterotopic bone, which occurred in 61%. None of the four patients who had an anterior ilioinguinal surgical approach had symptomatic heterotopic ossification. The average Glasgow outcome score was 3.9 out of 5, and 20 of the 23 patients, despite a prolonged convalescence, were able to return to independence and self-care. The authors conclude that patients with combined significant craniocerebral trauma and an operatively managed displaced acetabular fracture are likely to have compromised hip function despite a well-executed osteosynthesis. This was especially true for those patients over age 40 in this series. The authors suggest that if the fracture pattern permits it, the operative management of the acetabular fracture in these patients be by an anterior ilioinguinal approach, so as to minimize the formation of heterotopic bone.

Limb reconstruction versus amputation decision making in massive lower extremity trauma.

Massive lower extremity trauma, in particular open tibial fractures with associated vascular injuries, presents an immediate and complex decision-making challenge between a limb salvage attempt and primary amputation. Unfortunately, the literature to date is deficient in providing sound and defensible guidelines for primary amputation. Individual patient variables, specific extremity injury characteristics, and associated injuries must all be weighed before a decision can be reached. Further prospective studies are necessary before a well-defined protocol for primary amputation can be properly developed.

Expanding applications for the Herbert scaphoid screw.

A distinctive new bone screw developed for the management of scaphoid fractures and nonunions promises to have expanding applicability. Its utilization for osteochondral fractures, small joint arthrodeses, osteochondritic lesions, and fractures involving small bones is described. Its unique design affords significant advantages over more conventional management techniques of these problems.

Diagnostic dilemmas in foot and ankle injuries.

Differential diagnosis of foot and ankle injuries should include stress fractures of the great toe sesamoids, the shaft of the fifth metatarsal, and the tarsal navicular bone; transchondral talar-dome fractures; fractures of the os trigonum; and dislocating peroneal tendons. Diagnosis of these injuries is challenging because the initial roentgenograms often are normal, and special clinical tests and ancillary studies are required.

Similarity in yolk-platelet structure of an ancient bony fish (Acipenser) and an ancient reptile (Sphenodon).

Lipovitellin-phosvitin crystals from oocytes of the sturgeon (Acipenser boeri L.) and the tuatara (Sphenodon punctatus [Gray]) have been shown to he orthorhombic like all such known crystals from vertebrates higher than cyclostomes. Lattice parameters and projected crystal views also resembled closely the hitherto known cases. The high evolutionary conservation of this crystal structure probably reflects a cell-biological significance of the tertiary structure of crystal constituents, especially of the lipovitellines. A comparative consideration of crystallographic data from cyclostomes and higher vertebrates suggests that cyclostomes started with one species and all higher vertebrates with two species of lipovitellin molecules.

Pelvic ring disruptions with symphysis pubis diastasis. Indications, technique, and limitations of anterior internal fixation.

The management of disruption of the pelvic ring is both complex and controversial. Twenty-four injuries associated with symphysis pubis diastasis were reviewed to evaluate a two-hole plate technique of anterior internal fixation as compared to four-hole plate anterior fixation. The two-hole plate technique appears to be quite acceptable for maintaining reduction of the diastasis and therefore can be used to manage most anteroposterior compression injuries (those without complete posterior disruption). Vertical shear injuries, all of which are grossly unstable, can also be managed with anterior two-hole plates. However, this fixation method must be supplemented with some form of posterior stabilization to maintain pelvic ring reduction.

Skeletal management of humeral shaft fractures associated with forearm fractures.

Nine cases of ipsilateral humeral shaft and forearm fractures in multiply injured patients were reviewed in an attempt to ascertain the preferred management of these complex injuries. Satisfactory anatomic and functional results were achieved only in those cases treated by rigid internal fixation of the humeral fractures. Nonoperative management is associated with a significant risk of malunion or nonunion of the humerus.

Open tibial fractures with associated vascular injuries: prognosis for limb salvage.

Open tibial fractures complicated by limb-threatening vascular injuries present an infrequent but difficult management problem. Twenty-three cases were reviewed with an ultimate amputation rate of 61% (22% primary, 39% delayed). Crush injuries, segmental tibial fractures, and revascularization delays of greater than 6 hours were associated with a bad outcome. Guidelines for primary amputation (crushing injuries, delay in revascularization, segmental tibial fractures) are proposed and implications of limb salvage are reviewed.