Loss of the knee-ankle coupling and unrecognized elongation in Achilles tendon rupture: effects of differential elongation of the gastrocnemius tendon.

PURPOSE: The biarticular anatomy of the gastrocnemii is an important mechanism of knee-ankle coupling and differential elongation may affect this function leading to weakness of the push-off phase during the gait. Achilles tendon ruptures may cause detachment of the gastrocnemius tendon from the soleus aponeurosis with subsequent differential elongation of the individual subtendons. This study investigated the effects of such detachment by investigating tendon fusion levels of the two muscle groups, and the effect of sequential differential elongation of the gastrocnemius on the Achilles tendon resting angle (ATRA) and to the knee-ankle coupling. METHODS: Conjoined tendon length (CTL) was measured in 23 cadavers. ATRA in knee extension (ATRA 0) and 90-degree knee flexion (ATRA 90) was measured with the gastrocnemius tendons (GT) intact, transected and with the gap reduced in 5-mm increments. In 15 specimens, knee-ankle coupling was examined. RESULTS: Considerable anatomical variation was present with CTL ranging from 2 to 40% of fibular length. In the intact triceps, surae ATRA 0 differed from ATRA 90 by 6 degrees (p < 0.001). Cutting the gastrocnemius caused an immediate separation of the tendon ends by 19 mm. ATRA 0 and ATRA 90 increased 8 and 4 degrees (p < 0.001), significantly larger increase for ATRA 0 (p < 0.001). Lengthening the gastrocnemius 10 mm altered the coupling point 10 degrees towards dorsiflexion. Transfixing the gastrocnemius at the level of the gap where the Achilles was sectioned, decoupled the knee-ankle coupling in all but two specimens. A moderate correlation between CTL and length of the medial gastrocnemius tendon was found. CONCLUSIONS: A greater relative ATRA 0 than relative ATRA 90 indicates differential elongation of the gastrocnemius. By elongating the gastrocnemius the knee-ankle coupling point shifts dorsally, and 20 mm elongation completely decouples the knee-ankle coupling. Independent lengthening of the gastrocnemius may explain the loss of power experienced by some patients following acute Achilles tendon rupture despite what would appear to be appropriate approximation of the ruptured tendon ends. Recognizing this occurrence is crucial when treating Achilles tendon ruptures and such patients require surgical correction in order to avoid long-term weakness of push-off strength.

Arthroscopic subacromial decompression results in normal shoulder function after two years in less than 50% of patients.

INTRODUCTION: The aim of this study was to evaluate the outcome two years after arthroscopic subacromial decompression using the Western Ontario Rotator-Cuff (WORC) index and a diagram-based questionnaire to self-assess active shoulder range of motion (ROM). METHODS: Outcomes in 80 patients with impingement of the shoulder undergoing arthroscopic subacromial decompression were prospectively assessed preoperatively, at three months and at two years post-operatively using the WORC index. All patients had received non-operative treatment for at least six months before undergoing surgery. Active range of motion was measured preoperatively by the examining physician and at two years by the patient him-/herself using a diagram-based questionnaire to self-assess active shoulder ROM. A total of 75 patients (94%), of whom 31 were women, completed the study. The median age was 56 years. In all, 31 patients had additional resection of the acromioclavicular joint. RESULTS: WORC scores improved significantly from preoperatively (median: 1,392) to three months (median: 204) and two years post-operatively (median: 243) (p < 0.001). A clinically significant decrease in the WORC index was observed in 83% of patients, but only 45% reported near normal or normal WORC scores, and 56% presented with a reduced active ROM at two years. CONCLUSION: Arthroscopic subacromial decompression -appears effective in alleviating symptoms in patients with subacromial impingement who are resistant to conservative treatment, but can only be expected to restore normal shoulder function as measured by the WORC in less than 50% of the cases. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Ultrasound in the diagnosis and treatment of developmental dysplasia of the hip. Evaluation of a selective screening procedure]. / Ultralydskanning ved diagnostik og behandling af hoftedysplasi. Vurdering af en selektiv screeningsprocedure.

INTRODUCTION: With the intention of reducing the treatment frequency of Developmental Dysplasia of the Hip (DDH), two hospitals in Copenhagen implemented a screening and treatment procedure based on selective referral to ultrasonography of the hip (US). This paper describes and evaluates the procedure. MATERIALS AND METHODS: The procedure defines procedures for referral, diagnosis, treatment and follow-up of DDH. From 1998 to 2003 children with risk factors or with positive Ortolanis or Barlows test were referred to US. RESULTS: The treatment rate was 0.47%, and the rate of late diagnosed cases 0.03%. No relationship was seen between morphological parameters at the first US and the outcome of hips classified as minor dysplastic or not fully developed (NFD). A statistically significant relationship was seen between the degree of dysplasia and the time until US normalization of the hips (p= 0.02). There was no relapse of dysplasia after treatment. The median duration of treatment was six, eight and nine weeks for mild, moderate and severe dysplasia respectively. CONCLUSION: The procedure resulted in a low rate of treatment and a small number of late diagnosed cases. Prediction of the outcome of minor dysplastic/NFD hips must be based on a minimum of two US. An individualization of the treatment length was possible, and treatment length could be shortened in many cases. Compared with the incidence of DDH in Gentofte Hospital before the use of US, we suggest that this selective ultrasound screening procedure is worthwhile.

[Treatment of patellofemoral arthritis with patello-femoral arthroplasties]. / Behandling af patellofemoral artrose med en patellofemoral alloplastik.

INTRODUCTION: Patellofemoral arthritis is a common entity and patellofemoral arthroplasties have been performed since the 1970s. However, follow-up studies are few, and the optimal indication for the operation has yet to be established. This study concentrates on the gains in patient-reported quality of life parameters achieved by the operation. MATERIAL AND METHODS: Of 26 patients operated with 31 Richards Model Patella II patellofemoral arthroplasties, 17 patients with 20 arthroplasties were available for clinical review using two subjective/objective scoring systems and one patient administered self evaluation form median 7.7 years after the operation. RESULTS: The revision rate for the prosthesis was low (3%). A frequency of short-term complications of 15% and of later surgical procedures of 20% was observed. The American Knee Society Score showed 65% excellent or good, 20% fair and 35% poor results. The results of the patient administered KOOS showed significant improvements for the subcategories ''symptoms'', ''pain", ''activities of daily living" and ''quality of life". The worst results were seen among patients with pre-arthritic patellofemoral pain syndrome. CONCLUSION: 7-8 years after patellofemoral arthroplasty survival of the prosthesis is good. The clinical result is unpredictable. Most patients can expect a reduction in their level of pain and a higher level of daily living activities. The level of sports and recreational activities did not increase, even among younger patients. Patients with patellofemoral pain before radiological signs of arthritis are present in the joint cannot expect a measurable effect from the operation.