Intra-articular reconstruction of the anterior cruciate ligament with and without extra-articular supplementation by transfer of the biceps femoris tendon.

In a retrospective study to determine whether the efficacy of intra-articular reconstruction of the anterior cruciate ligament is improved by an extra-articular transfer of the biceps femoris tendon, we compared the results in a group of forty-three patients in whom the advancement procedure had been done with those in a group of fifty patients in whom it had not. The minimum length of follow-up was twenty-four months. There was no significant difference between the two groups, and we concluded that advancement of the biceps femoris tendon does not improve the efficacy of an intra-articular reconstruction of the anterior cruciate ligament.

The results of replantation after amputation of a single finger.

We reviewed fifty-nine consecutive cases of patients who had replantation of a single finger (excluding the thumb) after traumatic amputation, with an average follow-up of fifty-three months. Fifty-one (86 per cent) of the replanted fingers survived. Survival was found to be affected by the age of the patient, the number of vessels that were anastomosed, and the replantation experience of the surgeons. The survival rate was not affected by the gender of the patient, the mechanism of injury, or which finger was amputated. As compared with survival only, the functional results were most dependent on the level of amputation. The proximal interphalangeal joint in amputated fingers that were replanted distal to the insertion of the flexor superficialis tendon had an average range of motion of 82 degrees after replantation, while those amputated proximal to the insertion had an average range of motion of only 35 degrees after replantation. The average operating time was six hours and ten minutes, and the average time until the patient returned to work was 2.3 months. Based on this experience, it is our opinion that replantation of a single finger that was amputated distal to the insertion of the flexor superficialis tendon is justified, but that replantation of a single finger that was amputated proximal to this insertion is seldom indicated.

Evaluation of the polypropylene braid as a prosthetic anterior cruciate ligament replacement in the dog.

The purpose of this scientific investigation, made prior to 1977, was to determine the suitability of a polypropylene prosthetic ACL. The 3.6 mm diamond-braided prosthesis was implanted in 17 dogs. The device was passed through a trough on the anteromedial side of the tibial crest and over the top of the lateral femoral condyle. The device was internally fixed at both ends to bone using a bushing-lag screw technique which resulted in solid prosthesis immobilization at the time of surgery. Animals were necropsied at 3, 6, or 10 months after implantation. There was partial or total disruption of the prosthesis in all cases. Destruction of the prosthesis was attributed to excessive viscoelasticity of the device and fatigue failure. Based on this study, prosthetic ACL replacement using this device is not recommended.

Posterior cruciate ligament reconstruction by transfer of the medial gastrocnemius tendon.

A retrospective study to determine the efficacy of medial gastrocnemius tendon transfer for symptomatic PCL instability is presented. Results from a group of 31 patients undergoing this procedure were compared with a group of 8 patients managed conservatively while awaiting surgery. The mean injury to follow-up interval was 82 months in the operated group and 104 months in the nonoperated group. The mean surgery to follow-up interval was 53 months. Sixty-nine percent of surgical patients were subjectively improved; however, 29 (91%) continued to have pain and 19 (59%) continued to experience giving way. Thirteen patients from the operated group who had associated procedures performed were significantly better subjectively than those with no associated procedures (P less than 0.05). Physical examination demonstrated no difference in clinical laxity between the operated and nonoperated groups. Medial gastrocnemius transfer did not result in any significant reduction in anterior-posterior translation (KT-1000 assessment) when reconstructed knees were compared with control posterior cruciate deficient knees. Surgery, combined with subsequent immobilization, may have also been responsible for the significant reduction in lower limb function observed in the reconstructed patients. We do not recommend this procedure as a primary PCL reconstruction.

Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction.

The purpose of this clinical retrospective study is to determine whether a polypropylene braid (PB) used to augment an intraarticular autograft to reconstruct the anterior cruciate ligament (ACL) is safe and to determine whether the PB improves the efficacy of the procedure. A simultaneous review was performed of patients who had undergone an intraarticular ACL reconstruction using an autograft composed of the central quadriceps tendon, prepatellar periosteum, and patellar tendon left attached distally to the tibial tubercle and of patients who had undergone the same procedure with PB augmentation of the autograft. Preoperatively, all patients had chronic ACL insufficiency and were experiencing symptomatic giving way. A subjective questionnaire and a physician examination (JHR) were completed on each patient. Objective laxity and functional testing, including KT 1000 arthrometer measurement, Cybex isokinetic strength analysis, and one leg horizontal hop for distance, were performed. Six radiographs of each operated knee were obtained. Results were statistically analyzed. Thirty-eight of 43 (88%) nonaugmented procedures performed were reviewed, with a mean followup of 64 months. Forty-five of 48 (94%) PB augmented reconstructions with a minimum followup of 42 months (maximum 57 months, mean 50 months), were reviewed. On objective laxity and function testing, the PB augmented patients had better results than the nonaugmented patients. On subjective questioning, physician's examination, and radiographic analysis, the PB augmented results were significantly better. There were 12 (32%) knees with recurrent symptomatic giving way in the nonaugmented group and 5 (11%) in the PB augmented group. Chrondromalacia patellae and arthrofibrosis were seen in both groups. No adverse reaction to the PB was seen. We conclude that the PB is safe and that PB augmentation improves the efficacy of the intraarticular autograft to reconstruct the ACL.

Movement diagram and "end-feel" reliability when measuring passive lateral rotation of the shoulder in patients with shoulder pathology.

BACKGROUND AND PURPOSE: Findings related to joint function can be recorded with movement diagrams or by characterizing the "end-feel" according to the procedure described by Cyriax. Because both methods are used to classify pain and resistance in relation to joint range of motion (ROM), the purpose of this study was to simultaneously evaluate the reliability of these categorizations in a patient sample. SUBJECTS: Two physical therapists performed 2 assessments of passive lateral rotation of the shoulder in 34 patients. METHODS: Pain and resistance findings were recorded using movement diagrams and end-feel categories. Intraclass correlation coefficients (ICC[2,1]) were used to analyze the ratio (movement diagram) data, and kappa statistics (kappa) were used to analyze the categorical (end-feel) data. RESULTS: Intrarater ICCs varied from .58 to .89. Interrater ICCs for locating maximum pain and resistance in joint ROM varied from .85 to .91. Other interrater ICCs were lower (ICC = .34-.88). Intrarater kappa values for end-feel were moderate (kappa = .48-.59), and interrater kappa values were substantial (kappa = .62-.76). CONCLUSION AND DISCUSSION: Movement diagram measures conceptually related to the end of joint ROM and end-feel were highly reliable. This finding and the fact that additional end-feel categories were introduced in the study may partially explain the end-feel reliability findings. Consideration of their use in future studies may help to determine their clinical utility.

Arthroscopic treatment of triangular fibrocartilage tears.

Lesions of the TFCC are more frequently implicated as a cause of ulnar-sided wrist pain. Accurate diagnosis of TFCC pathology must be based on a thorough history and physical examination. Imaging modalities of particular use include plain radiographs, triple compartment arthrography, and MR imaging. The most sensitive and accurate diagnosis of the extent as well as the clinical significance of intra-articular pathology on the ulnar side of the wrist is by means of the arthroscope. With the advent of smaller and more elaborate arthroscopic instrumentation, the ability to perform arthroscopic surgery on the TFCC has dramatically increased over the past decade. The present arthroscopic treatment of traumatic central and radial lesions consists of debridement of unstable flaps, whereas dorsal and ulnar-sided lesions can be directly repaired. Centrally located degenerative perforations can be debrided in conjunction with an arthroscopic wafer procedure on the distal ulna.

Patient rating of wrist pain and disability: a reliable and valid measurement tool.

OBJECTIVE: The goal of this study was to develop a reliable and valid tool for quantifying patient-rated wrist pain and disability. DESIGN: Survey, tool development, reliability, and validity study. SETTING: Upper extremity unit. PARTICIPANTS: One hundred members of the International Wrist Investigators were surveyed by mail to assist in development of the scale. Patients with distal radius (n = 64) or scaphoid (n = 35) fractures were enrolled in a reliability study, and 101 patients with distal radius fractures were enrolled in a validity study. INTERVENTION: Information from the expert survey, biomechanical literature, and patient interviews was used as a basis for item generation and definition of structural limitations for a scale that would be practical in the clinic. Patients with distal radius or scaphoid fractures completed the Patient-Rated Wrist Evaluation (PRWE) on two occasions to determine test-retest reliability. Patients with distal radius fractures (n = 101) completed the PRWE and the SF-36 and were tested with traditional impairment measures at baseline and at two, three, and six months after fracture to determine construct and criterion validity. MAIN OUTCOME MEASURES: Reliability coefficients (ICCs) and validity correlations (Pearson product moment correlations). RESULTS: Patient opinions on pain and on ability to do activities of daily living and work were thought to be the most important dimensions to include in subjective outcome tools. Brevity and simplicity were seen as essential in the clinic environment. A fifteen-item questionnaire (the PRWE) was designed to measure wrist pain and disability. Test-retest reliability was excellent (ICCs > 0.90). Validity assessment demonstrated that the instrument detected significant differences over time (p < 0.01) and was appropriately correlated with alternate forms of assessing parameters of pain and disability. CONCLUSIONS: The PRWE provides a brief, reliable, and valid measure of patient-rated pain and disability.

Arthroscopic surgery of the wrist.

This article has presented the technique of wrist arthroscopy, reviewed the principles and strategy of arthroscopy, described arthroscopic wrist anatomy, compared wrist arthroscopy and arthrography, and illustrated several cases of arthroscopic wrist surgery. We have not discussed indications. More cases and careful follow-up studies must be performed before definite recommendations can be made. The authors are encouraged by their early achievement and believe that the future of arthroscopy of the wrist is exciting. The hand surgeon who performs wrist arthroscopy considers wrist patients to be among the most interesting. The authors believe that arthroscopic surgery will become as important diagnostically and therapeutically in the wrist as it has in the knee.

Use of laser Doppler flowmetry to determine blood flow in and viability of island axial pattern skin flaps in rabbits.

Perfusion and viability of island axial pattern skin flaps were tested in 37 healthy New Zealand white rabbits, using laser Doppler monitoring of blood flow in the capillary loops and the subpapillary plexus of the dermis. Skin flaps, selected on the basis of the caudal superficial epigastric vein and artery, were lifted and replaced in their original locus after selective occlusion of their vascular pedicles. Subjects were allotted into groups: control group (n = 10); arterial occlusion (n = 7); venous occlusion (n = 10); and arterial and venous occlusion (n = 10). The rabbits were monitored from 48 hours before surgery until euthanasia 48 to 72 hours after replacement of the flap. Flap viability was assessed on a clinical basis, using a comparative scoring method based on a numeric scale. The degree of necrosis in histologic sections was evaluated, using a scoring system. Laser Doppler measurements were obtained on 3 consecutive days before surgery, to establish the normal basal blood flow in the skin. Postsurgical measurements were obtained at 2-hour intervals for the first 8 hours and at 24, 48, and 72 hours after surgery. Measurements of basal blood flow varied significantly (P less than 0.05) from site to site on the surface of individual flaps and over time. When laser Doppler flowmetric (LDF) measurements from 6 sites on a flap were used as a measure of laser Doppler flow for the total flap, there was no significant difference between contralateral flap areas outlined on the abdomen of the rabbits. Temporal variations over 3 days for each rabbit or among rabbits were not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Validity of pulp-to-palm distance as a measure of finger flexion.

This study investigated the validity of pulp-to-palm distance measures as clinical indicators of finger flexion capacity. Pulp-to-palm distance and goniometry of the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints were measured by a single tester in 50 patients with abnormal digital flexion using a computerized hand assessment system. The correlation between pulp-to-palm distance measurements and total finger flexion measures obtained by goniometry, was moderate (r=-0.46 and -0.51). This indicates that the measures are not interchangeable. The relationship between an upper extremity disability score (DASH) and restricted motion was stronger for the goniometric measurements (r=0.45, P<0.01) than for the pulp-to-palm distance measurements (r<0.30, P>0.01). Both types of range of motion measurements were able to discriminate between minimal and substantial upper extremity disability. Further methodological evaluation is required to support the use of pulp-to-palm distance measures as an outcome indicator.

The outcome of tendon transfers for C6-spared quadriplegics.

The purpose of this study was to review retrospectively and evaluate a uniform group of C6-spared quadriplegics who had similar surgical procedures. Eight patients undergoing 12 procedures were reviewed at an average of 3.8 years follow-up. There were three bilateral procedures. All patients had extensor carpi radialis longus to flexor digitorum profundus and brachioradialis to flexor pollicis longus transfers to improve grip strength and key pinch. All patients reported subjective improvements in quality of life, activities of daily living and patient-centred goals. There were six excellent and two good results. Objective improvements included mild improvements in key pinch and grip strength.

Functional outcome of upper limb tendon transfers performed in children with spastic hemiplegia.

Children with spastic hemiplegia often present with upper limb muscle imbalance. The purpose of this paper was to determine whether reconstructive surgery improved their functional ability. 17 children under the age of 16 years with spastic hemiplegia underwent reconstruction that included tendon transfers, tendon lengthenings and thumb metacarpophalangeal fusion. They were assessed pre-operatively and at an average follow-up period of 2.6 years. Children's abilities were classified according to House's functional rating scale. Tendon transfers improved functional grading by two grades, from good passive assist to fair active assist. Improvement in the arc of wrist motion and forearm rotation was also seen. Parental satisfaction was high. Reconstructive surgery improved the functional abilities in this group of children with spastic hemiplegia.

The role of arthroscopy in arthritis. "Ectomy" procedures.

Advances in arthroscopic techniques and instrumentation have enabled the surgeon to extend the therapeutic possibilities of wrist arthroscopy. The introduction of suction punches and smaller, lighter motorized resectors and burrs have facilitated the arthroscopic removal of bone and soft tissue. Arthroscopy provides the surgeon with a magnified view of all intra-articular structures, including those areas difficult to access via an arthrotomy. With the new instrumentation and the excellent views, bone and soft tissues can be resected with precision. Now the wrist arthroscopist can effectively perform a synovectomy; debride a torn TFC, chondral defects, and osteoarthritis; remove loose bodies; and resect the distal ulna and carpal bones. The surgeon should follow the anatomic principles that have been developed for open surgical procedures. Arthroscopic surgery is minimally invasive, hence patients rehabilitate quickly with fewer complications. "Ectomy" surgery of the wrist requires a higher level of skill from the surgeon but, when mastered, provided considerable benefit to the patient.

Inter-rater agreement and accuracy of clinical tests used in diagnosis of Carpal Tunnel Syndrome.

A sample of 42 subjects (84 hands) with complaints of pain, numbness and/or tingling were used to study the inter-rater agreement and accuracy of seven clinical tests which can be used to assist in the diagnosis of carpal tunnel syndrome (CTS). A 'gold standard diagnosis', defined as a clinical diagnosis of CTS rendered by one of two hand surgeons and supported by electrodiagnostic evidence of CTS, was used to classify the 84 hands as to the presence of CTS. Two therapists were blinded to patient history, electrophysiology, diagnosis and all evaluations performed by the other therapist, until clinical testing was completed. Tests performed included: wrist flexion, wrist extension, Tinel's, tethered median nerve (TMN), pinch, vibration and Semmes-Weinstein monofilament (SWMF) tests. Substantial inter-rater agreement was observed between the two therapists for five of the clinical tests (k > 0.71) with SWMF and TMN having lower agreement. The most accurate test was Phalen's wrist flexion test. Good accuracy was demonstrated by pinch and vibration tests. Tinel's test was characterized by lower sensitivity, but false positives were rare. Wrist extension and TMN tests had poor sensitivity. SWMF testing was very sensitive, but a high number of false positives occurred when 'normal' was classified as 2.83. Reliability and accuracy of these tests supports their use as components of a clinical diagnosis of CTS.