Seven years follow-up after ankle inversion trauma.

During one year all ankle inversion injuries seen at the acute ward of our institution were divided into grades of severity and classified according to the maximal area of tenderness at the time of clinical examination. Seven years later 648 of the subjects (91%) evaluated their ankle with the help of a questionnaire. Location of maximal tenderness at the time of injury was: lateral fibular ligaments 61%, lateral midfoot ligaments 24%, base of the fifth metatarsal/peroneal tendons 5% and combined lesions 8%. 39% were considered minor, 46% were moderate, and 15% severe. All cases followed a functional treatment protocol. Seven years post- injury 32% reported chronic complaints of pain, swelling or recurrent sprains. 72% of the subjects with residual disability reported that they were functionally impaired by their ankle - in most cases a question of not performing sports at a desired level. 4% experienced pain at rest and were severely disabled. 19% were bothered by repeated inversion injuries - 43% of these subjects felt that they could compensate by using an external ankle support. There was no correlation between the severity of the sprain as judged at the time of injury and the frequency of residual disability or between the area of maximal tenderness at the time of injury and the area of maximal pain at the time of follow-up.

Sensori-motor control of the uninjured and injured human ankle.

This review focuses on the role of sensori-motor function in the healthy as well as the functionally unstable ankle. The concept functional ankle instability--a widely used term, which has no universally agreed upon definition-as well as the sources of peripheral afferent information measured with different sensori-motor tests are discussed. The protective mechanisms against sudden ankle inversion are reviewed, and models that directly connect deficits in kinaesthesia and peroneal reflex reaction to an increased risk of sustaining unprovoked ankle inversion injuries are presented.

Increased inversion angle replication error in functional ankle instability.

The inversion-angle replication error of the ankle joint was measured in subjects with a functionally stable or unstable ankle. Testing was performed as a passive set-active replication design. The absolute replication error on the unstable side of 23 unilaterally, functionally, and mechanically unstable subjects was found to be significantly greater (2.5 degrees) than the error on the healthy contralateral side (2.0 degrees ; P < 0.05) and the error in a group of 40 ankle healthy controls (1.7 degrees; P < 0.01). In 10 ankle-healthy high-level cross-country runners the replication error was reduced by 38% after warming up (P = 0.04).

The effect of anterior cruciate ligament trauma and bracing on knee proprioception.

We studied the effect that chronic anterior cruciate ligament disruption, functional bracing, and a neoprene sleeve have on knee proprioception by measuring the threshold to detection of passive knee motion in all three conditions. The threshold to detection of passive knee motion was worse in knees with chronic anterior cruciate ligament insufficiency when compared with uninjured knees. This difference was small, on average an additional 0.28 degree of flexion-extension rotation was required for the anterior cruciate ligament-deficient knee before the subject detected motion, and of questionable significance from a clinical and functional perspective. Wearing a functional brace or neoprene sleeve on the anterior cruciate ligament-deficient knee did not significantly change the threshold to detection of passive motion in comparison with the same knee without a brace, although improvements were observed. There was no relationship between the most common clinical means of characterizing altered biomechanics of the anterior cruciate ligament-deficient knee (that is, the magnitude of anterior-posterior knee laxity and the grade of pivot shift) and the threshold to detection of passive knee motion.

Ankle sensorimotor control and eversion strength after acute ankle inversion injuries.

We performed this study to monitor changes in ankle eversion strength and sensorimotor control functions after acute ankle inversion injury. Forty-four patients with clinical grade II to III first-time ankle inversion sprains were tested for 1) pathologic talar tilt and anterior talar translation at 1 and 12 weeks after injury; 2) isometric eccentric ankle eversion strength and 3) peroneal reaction time to sudden ankle inversion at 3, 6, and 12 weeks after injury; and 4) accuracy of inversion position assessment 1, 3, 6, and 12 weeks after injury. Not all patients could perform all tests at the early follow-up visits. There was mechanical instability in 19 of 40 tested patients at 1 week and in 4 patients at 12 weeks after injury. Eversion strength was 88% of the contralateral side 3 weeks after injury, rising to 96% after 12 weeks. The magnitude of error of inversion position sense was 190% of the contralateral side 1 week after injury; this was still affected after 12 weeks, but fell to 133%. Patients with pathologic talar tilt or anterior talar translation, or both, at 1 week after injury did not show significantly greater error in position assessment or reduction in eversion strength when compared with patients with ankles that remained stable after injury.

Ankle inversion injuries. The role of the dynamic defense mechanism.

We investigated the role of a muscular defense in the stabilization and protection of the ankle joint against sudden forced inversion. Ten volunteers with mechanically stable ankles were tested in different standing and walking situations using a trap door model and lower extremity electromyography and electrogoniometers. Peroneal electromyographic activity was observed 54 msec after the detection of ankle inversion. This latency was shorter when the ankle was already in inversion and longer with the ankle in eversion. Quadriceps and hamstring muscle electromyographic activity occurred 68 msec after the ankle inversion stimulus. Evidence of active eversion was seen 176 msec after sudden inversion. Active changes in knee and hip joint angles occurred even later. In contrast, the trap door rotated 30 degrees in approximately 80 msec. We conclude that the reflex reaction to sudden inversion is initiated at a peripheral level by the inversion motion followed by a reaction pattern mediated by spinal or cortical motor centers. Both peripheral and central reactions, however, seem too slow to protect the ankle in case of sudden inversion occurring at the time of heel contact.

Acute midtarsal sprains: frequency and course of recovery.

In a prospective consecutive registration of 711 ankle inversion sprains, the dorsal ligaments and capsule of the midtarsal joints were involved in 237 of the cases (33%), and in 172 cases (24%) only these joints seemed to be injured. A total of 162 isolated midtarsal injuries and 161 cases of isolated lateral talocrural lesions selected at random were followed using questionnaires 1, 3, 6, 9, and 12 months after injury. The frequencies of pain after 1 month and swelling after 1 and 3 months were significantly lower in isolated dorsal midtarsal sprains compared with isolated lateral talocrural sprains. At the following controls, frequencies of both pain and swelling were the same for both groups. Functional instability appeared with the same frequency in both groups during the 12 months of follow-up. Regarding the social impact of the sprains, absence from work and sports did not differ between groups. When avulsions were present in midtarsal injuries recovery was slow, with two thirds of the patients experiencing pain after 6 months. We conclude that the dorsal midtarsal sprain is a common entity with a course of recovery and a frequency of residual symptoms very like the lateral talocrural lesions.

Chronic critical leg ischaemia must include leg ulcers.

OBJECTIVES: In a previous series on conservative treatment in patients with leg ulcers and severe arterial occlusive disease (systolic digital blood pressure (SDBP) < 30 mmHg) a 70% risk of leg amputation and a negligeable potential for ulcerhealing was found. This series assess the efficacy of arterial reconstruction in such patients. DESIGN: Retrospective study of consecutive patients in a department of vascular surgery and of dermatology in cooperation with the wound healing center. MATERIAL AND METHODS: Thirty-nine patients with 42 ulcerated legs underwent arterial revascularisation. 88% of the procedures were distal to the inguinal ligament. MAIN RESULTS: One patient died postoperatively (3%). Seven (18%) had wound complications, but none had graft infections. After 1 year the cumulative secondary patency was 90%, ulcer healing 70% and the limb salvage 90%. Thus only four legs (10%) had been amputated. CONCLUSIONS: Arterial revascularisation for leg ulcers is indicated when conservative treatment fails. Legs with ulceration and SDBP < 30 mmHg should be included in the concept of chronic critical ischaemia.

Are hard-copy prints from peroperative fluoroscopy images useful as documentation?

We have examined the applicability of peroperative image documentation, in promoting early mobilization after osteosynthesis and saving the standard X-ray examination. One hundred and twenty-three patients with proximal femoral fractures were included in the investigation. Hard-copy reprints were recorded from peroperative fluoroscopy images by Fuji Film Thermal Imaging System FTI 200. These reprints were compared with the standard X-rays to assess the quality of the osteosynthesis and possible restriction in mobilization. The specificity of finding an unstable osteosynthesis was 0.40, whereas the sensitivity of finding a stable osteosynthesis was 0.96. In all, four unstable osteosyntheses were overlooked on the hard copy reprints. The specificity of finding patients in need of restricted mobilization was 0.44 and the sensitivity of finding patients allowed free mobilization was 0.93. Eight patients needing restricted mobilization were overlooked on the reprints. Hard-copy images do not safely reveal unstable osteosynthesis and cannot replace the standard X-rays taken postoperatively.

[Atlanto-axial rotation-fixation in a child with clavicular fracture]. / Atlantoaksial rotationsfiksering hos et barn med klavikelfraktur.

A case of an eight-year-old boy who had sustained both a fractured clavicle and rotatory atlanto-axial fixation is described. The last diagnosis was missed for four and a half months. The diagnosis was made in combination with cineroentgenography and computed tomography scanning. Conservative treatment with external traction was first attempted, after which the patient was operated twice with posterior fusion between C-1 and C-2. At six month follow-up the child was without pain, had neutral head holding and about two-thirds of normal rotation.

[Resection of the ulnar head in post-traumatic wrist pain]. / Resektion af caput ulnae ved posttraumatiske håndledsgener.

In a retrospective study, the effect of distal ulnar resection using the Darrach procedure was evaluated in 42 patients with post-traumatic distal radio-ulnar disability. Thirty women and 12 men, mean age 43 years were seen an average of seven years after the operation. In 57% of the cases the primary trauma was a Colles fracture. The main indication for operation was pain radiating from the distal radio-ulnar joint (83%), but seven patients were without substantial pain. 79% of the patients felt relief of pain after the operation, but 62% still suffered from occasional wrist pain. Twenty-six patients had a supination and a pronation of > or = 150 degrees postoperatively. Thirty-three patients had a dynamic handpower of > 60% of the opposite hand postoperatively. Ten patients stopped working or changed to less physically demanding jobs after the primary trauma. Three patients from this group could after the operation return to their primary physically demanding jobs. Radiographs showed no progress of radiocarpal osteoarthritis during the follow-up period. The Darrach procedure could relieve post-traumatic distal radioulnar pain conditions without adverse effect on radiocarpal function and alignment. Patients who only had mild pain symptoms preoperatively presented unsatisfactory postoperative results.

Pyoderma gangrenosum complicated by necrotizing fasciitis.

Necrotizing fasciitis is a potentially life-threatening infection that may resemble extensive pyoderma gangrenosum. The treatment of the two diseases is, however, different, and differentiating them is therefore essential. A case is presented in which necrotizing fasciitis appeared as a complication of pyoderma gangrenosum. The successful treatment is described, and the differential diagnosis of the two entities is presented. The need for early and aggressive treatment of necrotizing fasciitis is stressed.

Epidemiology of sprains in the lateral ankle and foot.

The epidemiology of sprains in the lateral ankle and foot was investigated in a prospective study at the casualty ward at Hillerød County Hospital. During one year, 766 patients were registered. The overall sprain incidence was 7/1000 person-years. The incidence was highest for young males. After the age of 40 years, the incidence was higher for women than for men. Most sprains were sustained during sport, but, with increasing age, other activities became dominant. Sixty-one percent of the lesions were located around the lateral ankle, and 24% were located on the lateral midfoot.

Proprioception at the ankle: the effect of anaesthetic blockade of ligament receptors.

Seven subjects with normal joints were tested for active and passive position sense of ankle inversion, peroneal reflex reaction time to sudden ankle inversion, and postural stability during single-leg stance. The tests were performed before and after regional block of the ankle and foot with local anaesthetic. Passive position sense, assessed with the muscles relaxed, was greatly impaired by anaesthesia but active position sense, with the calf muscles activated, was preserved, and the peroneal reaction time to sudden ankle inversion was not altered. The magnitude of postural sway during single-leg stance was also unchanged by anaesthesia of the ankle and foot. The results suggest that the afferent input from intact lateral ankle ligaments is important in sensing correct placement of the foot at heel-strike, but that this input can be replaced by afferent information from active calf muscles. Afferent input from these muscles seems also to be responsible for dynamic ankle protection against sudden ankle inversion and is adequate to allow stable single-leg stance.

Long-term follow-up of the cemented Caffinière prosthesis for trapezio-metacarpal arthroplasty.

20 patients with 22 Caffinière prostheses in the trapezio-metacarpal joint were evaluated at a median of nine years after operation. The indication was degenerative osteoarthrosis in 20 cases and rheumatoid arthritis in two cases. We found 18 of the 22 (82%) original prostheses still in place, with satisfactory pain relief and good function. Three hands had been revised due to aseptic loosening, with replacement of two cups and one total prosthesis. Two of the revised prostheses were functioning well 6 1/2 and 10 years after the revision. We conclude that function does not deteriorate within the first nine years, that late loosening is not a significant problem with this prosthesis and that, if aseptic loosening occurs, it is possible to obtain good results by replacing the loose component.

Early mobilizing treatment for grade III ankle ligament injuries.

Eighty patients with grade III lateral ligament ruptures were treated either with total immobilization in a walking plaster cast or early mobilization in a stabilizing orthosis. The criterion for entrance was a talar tilt of more than 9 degrees and an anterior translation of more than 10 mm at stress radiography, a previously stable ankle, and a contralateral ankle showing normal stress radiographic values. Ninety-one percent of the patients were evaluated at 7 weeks, 3 months, and 1 year postinjury. While functionally treated patients reached normal mobility and resumed work and sports earlier than immobilized patients there were no differences between the treatment groups in ankle stability or symptoms during activity after 1 year. Ninety-five percent of the ankles in either group were mechanically stable after treatment. Residual symptoms were present 1 year postinjury in 13% of the functionally treated ankles and in 9% of the cast-mobilized ankles. In lateral ankle ligament ruptures causing gross mechanical instability early mobilization results in a better early functional result; however, at 1 year postinjury there was no statistically significant difference in outcome as compared to cast-immobilized ankles.

Prolonged peroneal reaction time in ankle instability.

The peroneal reflex time to sudden ankle inversion and the postural control of 15 athletes with functionally instable ankles were compared with 15 stable controls. A trapdoor produced sudden ankle inversion. Surface electrodes recorded electromyographic activity of the peroneal muscles. Postural sway was expressed by a transverse sway value obtained during single limb stance on a force plate. Increased postural sway was found in subjects with functional instability (p less than 0.01). This is in accordance with previous studies. Functionally instable subjects also displayed an increased peroneal reaction time (p less than 0.01) supporting the theory that functional instability is induced by a proprioceptive reflex defect. Nine of the 15 instable subjects were unilaterally instable and showed lower peroneal reaction time and postural sway values for the stable ankle, but the difference was not significant. There was a high degree of correlation between postural sway and peroneal reaction time (Spearman's rho = .92). In ten functionally instable athletes tested with and without ankle taping, it could not be verified that a reflex enhancing effect of taping occurs through stimulation of cutaneous afferents.

[Arthrosis of the lower limb and running]. / Underekstremitetsartrose og motionsløb.

In order to assess whether running training for many years predisposes to arthrosis in the lower limbs, the hips, knees and ankle joints of 30 runners who began running training at the beginning of the nineteen fifties were examined. Three of these runners were no longer active. One of these had given up late in the nineteen seventies on account of arthroses in the upper and lower limbs i.e. changes which can scarecely be attributed to the stresses of running. The remaining 27 (90%) had run 20-40 km/week throughout 40 years. Subjective, objective and radiological data were compared with data from 27 non-active control persons who were comparable as regards age, weight/height and occupational stress with the runners. We found no differences in joint mobility, axial deviations or complaints of pain between the two groups. Radiologically, the distances between the osseous joint surfaces in the hip and ankle joints and the degrees of degeneration in the knees were assessed according to Ahlback's classification without any differences being found between the groups. Our results suggest that running training to a moderate extent for many years does not predispose to arthrosis in the lower limbs in healthy individuals.