Clinical outcome of isolated subcortical trabecular fractures (bone bruise) detected on magnetic resonance imaging in knees.

Isolated subcortical trabecular bone injury (bone bruise) has rarely been described. Our purpose is to report a series of patients who had a history of traumatic injury, knee effusion, normal radiographs, and initial equivocal physical examination for ligament and meniscal integrity, and who were found to have isolated injury of the trabecular bone on magnetic resonance imaging. We evaluated demographic data, physical examination findings, radiographs, magnetic resonance imaging, and clinical outcome for 23 patients. Follow-up data included time to return to preinjury activity level, International Knee Documentation Committee activity level rating before and after injury, and postinjury Lysholm scores. All magnetic resonance imaging scans were negative for associated grade III meniscal lesions and ligament injury. Time to return to preinjury activity level was under 7 months in 96% of the patients. Postinjury International Knee Documentation Committee rating was unchanged in 91% of patients. Postinjury Lysholm score was 90 or more in 91% of patients. We propose that the recognition of these injuries is important because magnetic resonance imaging can distinguish them from meniscal or ligament injury requiring surgical intervention (arthroscopy). If detected on magnetic resonance imaging as an isolated injury, surgical arthroscopy is unnecessary since these patients can be expected to recover well in the short term with restricted weightbearing and initial activity modification.

The terrible triad of the shoulder.

This case shows that the terrible triad of the shoulder-anterior dislocation, brachial plexus injury, and rotator cuff tear-can occur in younger populations than previously described. A high index of suspicion for this triad of injury should be maintained, particularly in those young individuals with grossly unstable shoulders. Once axillary nerve function has begun to return, simultaneous repair of all soft tissue injuries can lead to a stable, functional joint.

Early operative reconstruction of severe ligamentous knee injuries in patients with multiple trauma.

Although operative reconstruction of severe knee ligament injuries has been the preferred method of treatment, the timing of that reconstruction relative to the injury has not been previously addressed. In a retrospective review of multitrauma cases, we identified 32 patients with 34 severe knee ligament injuries. Of these 34 knees, 19 (56%) were treated with early reconstruction (within 2 weeks of injury). Of the remaining 15 knees, 8 were managed by delayed reconstruction at an average of 4.8 months after injury, and 7 knees were not surgically treated. All 19 knees treated by early operation were clinically stable, and 89% were pain free at an average of 25 months' follow-up. In contrast, only 13% of the knees treated by delayed or no reconstruction were clinically stable, 33% were persistently painful, and 40% required bracing intermittently to allow activities of daily living. In this study, patients treated by delayed reconstruction or non-operatively had poor functional results. We believe early operative reconstruction of severe knee injuries in multitrauma patients is crucial to maximize functional outcome and minimize long-term sequelae.

Operative treatment of fractures of the tibial plafond. A randomized, prospective study.

We performed a randomized, prospective study to compare the results of two methods for the operative fixation of fractures of the tibial plafond. Surgeons were assigned to a group on the basis of the operation that they preferred (randomized-surgeon design). In the first group, which consisted of eighteen patients, open reduction and internal fixation of both the tibia and the fibula was performed through two separate incisions. An additional patient, who had an intact fibula, had fixation of the tibia only through an anteromedial incision. The second group consisted of twenty patients who were managed with external fixation with or without limited internal fixation (a fibular plate or tibial interfragmentary screws). Ten (26 per cent) of the thirty-nine fractures were open, and seventeen (44 per cent) were type III according to the classification of Rüedi and Allgöwer. There were fifteen operative complications in seven patients who had been managed with open reduction and internal fixation and four complications in four patients who had been managed with external fixation. All but four of the complications were infection or dehiscence of the wound that had developed within four months after the initial operation. The complications after open reduction and internal fixation tended to be more severe, and amputation was eventually done in three patients in this group. At a minimum of two years postoperatively (average, thirty-nine months; range, twenty-five to fifty-one months), the average clinical score was lower for the patients who had had a type-II or III fracture, regardless of the type of treatment. With the numbers available, no significant difference was found between the average clinical scores for the two groups. All of the patients, in both groups, who had had a type-II or III fracture had some degree of osteoarthrosis on plain radiographs at the time of the latest follow-up. With the numbers available, there was no significant difference between the two groups with regard to the osteoarthrotic changes. We concluded that external fixation is a satisfactory method of treatment for fractures of the tibial plafond and is associated with fewer complications than internal fixation.

Caveat arthroscopy: definition and guidelines for prevention.

Caveat arthroscopy is defined as an arthroscopy done with the intention of managing intra-articular nonneoplastic disease that suddenly escalates into the surgical treatment of an extra-articular neoplasm. The term caveat arthroscopy is used to describe a maloccurrence, not an act of negligence. The purpose of this retrospective review is to provide examples of this entity, examine its consequences, and suggest guidelines for prevention. We identified 13 individuals who had caveat arthroscopy over a 6-year period. All but one case involved the knee. Diagnoses included 5 soft tissue sarcomas, 5 benign bone tumors, 2 skeletal sarcomas, and 1 benign soft tissue tumor. In each case, there were complications related to prereferral biopsy (ie, biopsy done before definitive management at a tertiary institution). Every subject had at least one untoward event consisting of either compartment contamination, inaccurate diagnosis, or delay in diagnosis. The best way to avoid the complications of caveat arthroscopy is to avoid the tendency to biopsy extra-articular lesions. Instead, adequate imaging of a suspected neoplasm should be done, and referral before biopsy should be considered.

An evaluation of cervical orthoses in limiting hyperextension and lateral flexion in football.

Three cervical orthoses often used in football to prophylactically limit motion and prevent the nerve injury known as "burners" were evaluated to determine their performance in limiting both hyperextension and lateral bending of the cervical spine. These orthoses have been used almost entirely on an empiric basis with little objective data to evaluate performance. A rope and pulley mechanism was used to pull the neck into hyperextension and lateral motion, with the only restraint being the various products tested. These trials were videotaped and the restriction provided by the collars was calculated from goniometric analysis of the projected images. These tests were performed to determine which products limit the mechanisms of the "burner" injury and thereby assess which braces might reduce or prevent the occurrence of these injuries. The results of the investigation indicate that all braces studied provided some degree of limitation in one of the mechanisms of injury, hyperextension. One brace performed superiorly in this respect. However, the other mechanism of injury, lateral bending, is inconsistently limited.

Arthroscopic synovectomy in sarcoid synovitis.

Chronic synovitis is an unusual manifestation of sarcoidosis but may be significantly disabling. Arthroscopic synovectomy can provide an excellent result, relieving discomfort and arresting the disease process, and should be considered in any patient whose synovitis has not responded to medical management.

The injury experience of the competitive athlete with a disability: prevention implications.

The purpose of this project was to describe the injury experiences of athletes with disabilities. A cross-disability instrument was developed to measure variables of interest. A retrospective survey was administered to 426 athletes who participated at the 1989 national competition of the National Wheelchair Athletic Association (NWAA), United States Association for Blind Athletes (USABA), and the United States Cerebral Palsy Athletic Association (USCPAA). The definition of injury was any trauma to the participant that occurred during any practice, training, or competition session that caused the athlete to stop, limit, or modify participation for 1 d or more. Thirty-two percent (N = 137) of the total respondents reported at least one time-loss injury. By organization, 26% of the total injuries were from the NWAA and 37% were from the USABA and USCPAA, respectively. The shoulder and arm/elbow accounted for 57% of the total NWAA injuries. Fifty-three percent of the injuries to the USABA athlete were to the lower extremity. Injuries to the USCPAA athlete were distributed among four body locations, knee (21%), shoulder (16%), forearm/wrist (16%), and leg/ankle (15%). The athlete with a disability demonstrated approximately the same percentage of injury as the athlete without a disability in similar sport activities. Biomechanical considerations of locomotion and specific sport skills should be analyzed by experts to reduce the percentage of injuries.

Open fractures of the diaphysis of the lower extremity in children. Treatment, results, and complications.

We reviewed the results of treatment of forty open diaphyseal fractures of the lower extremity in thirty-five children. The patients were between three and sixteen years old, and they had been managed between 1980 and 1988. The minimum duration of follow-up was one year. Eighty-six per cent of the patients had been injured in a motor-vehicle accident, and 74 per cent had associated injuries. Thirty-one of the fractures were Grade-II open or Grade-III open and seven were Grade-I open, according to the classification of Gustilo and Anderson. Two patients who had initially had a closed fracture were treated with a fasciotomy for a compartment syndrome, so these two fractures were included as open. Four other patients who had a Grade-II or III open fracture also needed a fasciotomy. All wounds were treated with immediate and repeat débridement and early soft-tissue coverage. Twenty-two fractures healed primarily. There were three early amputations. Twelve fractures that healed after six months were classified as delayed unions and three fractures were classified as non-unions because of the absence or arrest of healing, as seen on serial roentgenograms. Additional intervention was used to achieve union of eight of the fifteen fractures that had been classified as a delayed union or a non-union. Ten of the forty fractures were associated with infection, but osteomyelitis developed in only one patient. No patient had a growth arrest. Only one patient had a limb-length discrepancy that was more than two centimeters. Three early amputations and one delayed amputation were performed in patients who had a Grade-IIIC open fracture.

Reaction force patterns of injured and uninjured knees during walking and pivoting.

A precise knowledge of the biomechanical alterations produced by anterior cruciate ligament (ACL) damage would aid in selecting appropriate therapeutic intervention and monitoring rehabilitation. In an attempt to assess dynamic knee joint function, we compared the ground reaction force (GRF) and vertical couple patterns during walking and pivoting from an ACL-deficient population with those from a separate uninjured population. Statistical methods were used to quantitate the differences between the two populations for each force pattern in each functional task and to delineate the intervals of the force patterns in each functional task during which significant differences existed between the two populations. Our results indicate that significant differences exist between the GRF and vertical couple patterns of ACL-deficient subjects and uninjured subjects, but that onset and duration of these differences during stance phase vary among force components and tasks. The processing scheme extracts significant differences in the GRF and vertical couple patterns that would be lost in a comparison of a few pattern descriptors. Our results suggest that the vertical couple should be evaluated during assessment of pivoting maneuvers and show promise of providing useful information for assessment of knee dysfunction.

Application of laser Doppler technology to meniscal injuries.

It has been recognized for many years that the vascular supply to the meniscus has been extremely important in the potential for healing of a repaired meniscus. Early experimental work confirmed that meniscal defects that communicated with the peripheral vascular network would heal if repaired. However, those tears that did not communicate with the vascular bed would not heal even if repaired. Unfortunately, there has been no clinically applicable technique for evaluating blood flow in the torn meniscus. Experimental procedures using laser Doppler flowmetry have shown this to be a precise and simple tool for the evaluation of meniscal blood flow. Applications of this technique in the clinical situation show great promise in enabling the surgeon to make a decision to repair or remove the torn meniscus based on the blood flow in the remaining vascular bed.

Blood levels of bupivacaine after arthroscopy of the knee joint.

Toxic levels of bupivacaine have been reported in other types of surgery, but have not been previously noted in arthroscopic procedures. The purpose of this study was to evaluate bupivacaine levels after an intraarticular bolus of bupivacaine administered after arthroscopic surgery. Blood levels of bupivacaine were found to be significantly higher in patients in whom synovial surgery had been performed compared with those patients in whom the procedure involved only meniscal or articular cartilage surgery. A reduction in the bupivacaine dosage when the synovium has been resected or divided is recommended to keep the serum level below the potentially toxic range.

Slipped capital femoral epiphysis associated with Russell-Silver syndrome.

Slipped capital femoral epiphysis has been described in several syndromes associated with short stature and endocrine disturbances. I have presented a case of slipped capital femoral epiphysis in conjunction with Russell-Silver syndrome.

Lower extremity telescopic orthosis for immediate fitting in paraplegia.

For initial gait training with the paraplegic patient, a lower extremity telescoping orthosis has been developed. This brace eliminates the time-consuming fabrication, considerable weight, and cumbersome use of conventional knee-ankle-foot orthoses and is easily adjustable to a wide range of patients. Particularly during the early phase of rehabilitation, this brace offers significant advantages to the patient with lower extremity disabilities.

Osteotomy of the first metatarsal base for metatarsus primus varus.

An opening wedge osteotomy of the first metatarsal base using either iliac crest bone or the removed exostosis as a graft was used to treat metatarsus primus varus in 22 feet of 15 patients. The preoperative intermetatarsal angle averaged 15 degrees, with the final angle averaging 8 degrees. All osteotomies healed in 3 months with excellent cosmetic and functional results and no difference between iliac crest and exostosis grafts. We conclude that an opening wedge osteotomy of the first metatarsal base is a satisfactory method for the correction of metatarsus primus varus.

Patellar subluxation following plica resection.

In this paper, a case of patellar subluxation following the excision of a medial plica is presented. The biomechanical relationship between the medial plica and the patella is discussed and the need for a complete preoperative evaluation of the patient with a symptomatic plica is emphasized.

Osteomyelitis of the odontoid process.

Pyogenic osteomyelitis of the odontoid process is a rare condition requiring a high index of suspicion for diagnosis. The three cases presented illustrate that patients with severe neck pain, aggravated by rotation, and persistent fever without apparent source should be studied carefully to exclude infection of the C1-C2 area. The unusual anatomy of the C1-C2 articulation may make routine diagnostic studies difficult to interpret. Computed tomography, magnetic resonance imaging, and 111In-labeled white blood cell scans may improve diagnostic accuracy. Treatment includes rigid immobilization, high dose antibiotics, and surgical stabilization in selected cases.

EMG profiles of knee joint musculature during walking: changes induced by anterior cruciate ligament deficiency.

A tear of the anterior cruciate ligament (ACL) disrupts the delicate balance of static stabilizers of the knee, leading to significant alterations in joint kinematics. Little is known about the dynamic compensatory responses of the patient to these kinematic alterations. This lack of quantitative information on the muscle synergy patterns has limited the surgeon's ability to evaluate various operative and rehabilitative techniques. Twelve subjects with documented ACL deficiency for at least 1 year and 15 normal participants were studied. Each subject was asked to walk at free and fast speeds on a 12 m walkway. The right and left foot contact patterns and the linear envelopes from the surface electromyogram (EMG) patterns of the gastrocnemius, medial and lateral hamstrings, rectus femoris, and vastus lateralis were measured. Significant differences were found in the muscle synergy patterns during walking. During the swing-to-stance transition, the ACL-deficient subjects showed significantly less activity in the quadriceps and gastrocnemius muscles and more activity in the biceps femoris than in the normal group. During early swing, the vastus lateralis is more active than normal, and during midstance and terminal stance, the hamstrings appear to be less active than normal subjects. These dynamic compensatory mechanisms suggest that use of the hamstring tendons in reconstructive procedures may alter important compensatory mechanisms about the knee joint. Application of dynamic EMG techniques to the study of reconstructive procedures should provide additional information that will assist the clinician in the rational choice of a surgical procedure.

Maffucci's syndrome complicated by carcinoma of the breast, pituitary adenoma, and mediastinal hemangioma.

We have described a 39-year-old woman with Maffucci's syndrome, large mediastinal hemangiomas, infiltrating adenocarcinoma of the breast, and pituitary adenoma. This is the fifth reported case of Maffucci's syndrome with a coexistent pituitary adenoma, a frequency that cannot be explained by chance alone. There has been only one previously reported case in which the patient had a widened mediastinum, but the etiology was not discussed. Three of the four previously described patients with Maffucci's syndrome and a pituitary adenoma also had a proven or possible associated epithelial neoplasm. While this association is tenuous, it is considered worthy of comment.