Biomedical subjects
Publications and source records attributed to B R Bach.
When confronted with the challenge of hardware removal during revision shoulder stabilization procedures, specialized instrumentation such as the Instrument Makar staple driver/extractor may become necessary. The Synthes DHS/DCS coupler screw may be more readily available, and can effectively substitute for the Instrument Makar staple driver/extractor.
Over a 4-year period, hospital charges of 151 consecutive anterior cruciate ligament (ACL) reconstructions were retrospectively evaluated. Eighty-one patients who underwent a two-incision ACL central third autogenous patellar bone tendon bone reconstruction were compared with 72 patients who had a single-incision endoscopic reconstruction with a similar graft. Charges were adjusted for inflation. There was a statistically significant difference in hospital days (2.8 v 1.57, P = .0001), total hospital charges ($15,063 v $13,520, P = .0001), as well as operating room/hospital ward charges (P = .0001), pharmacy charges (P = .035), and physical therapy charges (P = .001). No statistical difference was observed for anesthesia or laboratory charges. A matched comparison of patients from each group who were in the hospital for 2 days showed a statistically significant reduction in operating room/hospital ward charges (P = .037), but no significant reduction in total costs. There was a trend in both groups toward shorter hospital stays in each successive year. The reduction in charges observed for the endoscopic procedure correlated with a reduction in postoperative hospital days.
Complications of patellar-tendon allograft for anterior cruciate ligament (ACL) reconstruction in ACL-deficient patients have focused on disease transmission, strength, survivorship, technique, and processing to decrease antigenicity. Little has been described in regard to intrinsic complications of patellar-tendon allograft. This article discusses our experience with a damaged patellar-tendon allograft that was abnormally long and had a large osseous intratendinous mass. Based on this experience, we make recommendations on evaluating and procuring patellar-tendon allografts that will help orthopaedic surgeons avoid intrinsic patellar-tendon allograft complications.
Four cases of failed Hauser procedures were treated with an osteotomy of the patellar tendon insertion and distal realignment. The patellar tendon insertion site was moved as a large bond block and positioned in neutral alignment as well as anterior to its previous position, effectively creating a "modified Maquet effect." Proximal realignment was performed in one patient. Intraoperative assessment of patellar tracking enabled accurate determination of optimal position. The clinical findings and the operative approach are described. All four patients experienced significant improvement from ther preoperative status.
Nine patients with distal biceps tendon ruptures that had been repaired anatomically with a double-incision technique were evaluated. All patients were men, whose average age was 46 years old (range, 31-66 years). Three patients injured their dominant extremity and 6 their nondominant extremity. This represents the largest series of operatively treated nondominant biceps ruptures with quantitative followup in the literature. All patients responded to a questionnaire, and had clinical, radiographic, and isokinetic testing. The average followup was 30 months (range, 12-57 months). Patients were pleased uniformly with their operative results, and all would have had surgery given the option again. Strength testing results of the dominant extremities revealed full return of forearm supination strength and elbow flexion strength. Endurance data also revealed full return when compared with controls. In nondominant extremities, a 14% supination strength deficit from expected values (corrected for dominance) and a 14% flexion strength deficit (also corrected) were observed in the 6 patients. A radioulnar synostosis that required resection developed in 1 patient. Anatomic repair of distal biceps tendon rupture gives consistently good results. Dominant extremities can achieve normal function, whereas nondominant extremities may require aggressive therapy to achieve maximal strength.
Interference screws are commonly used for graft fixation in arthroscopically assisted anterior cruciate ligament reconstruction. A potential complication with the use of interference screws is intraarticular violation of the screw tip. Postoperative radiographs often lend confusion to the exact screw location. We devised an anatomic-radiologic study to evaluate factors (including local anatomy, radiographic projection, and radiographic technique) in order to clarify these misunderstandings. We found that radiographic projection, obliquity, and the local bony anatomy contribute to erroneous radiographic interpretation. The most significant finding was that the lateral radiograph and cephalad oblique lateral radiographs frequently suggest screw tip violation of the joint when in fact it has not occurred. Caudal oblique lateral radiographs fail to raise concern even when joint violation by the screw tip has occurred. Good quality true anteroposterior radiographs appear most consistent in determining true screw tip location.
Earlier diagnosis and knowledge of the natural history of anterior cruciate ligament (ACL) injuries has made consideration of early operative treatment more important in the active patient at risk for further instability episodes. In a review of early operative treatment options, ACL repair alone has been disappointing for many patients, with long-term follow-up suggesting that the reinjury rate is high. Early repair with augmentation or reconstruction with hamstring or central third bone-tendon-bone graft yielded better results, but long-term follow-up is still needed, especially in the early reconstruction groups. Early ACL reconstruction, especially in patients with medial collateral ligament injury and/or extra-articular surgery, is associated with an increased incidence of arthrofibrosis. The methods of reporting data in these studies have also presented problems in interpreting and comparing data from one study with those of another. Further standardization will be needed if literature regarding ACL surgery can be easily compared from series to series.
Peripheral lateral meniscal tears are amenable to meniscal repair. Rasp abrasion and fibrin clot deposition along with vascular access channels are advances that, one hopes will increase healing rates of meniscal repairs. A basic principle that is not emphasized in the literature is how to perform the surgical approach to the lateral meniscus for safe placement of a meniscal repair retractor. This article reviews the anatomical planes of which the surgeon must be cognizant to facilitate retractor placement.
Arthroscopic surgery for treatment of pathologic meniscal lesions has become the most commonly performed orthopaedic procedure in the United States. This article reviews the diagnosis, evaluation, and subsequent treatment of meniscal tears in the knee.
Complications of metallic hardware about the shoulder have been well documented in the literature. This case report presents a recreational athlete who presented to our office with a painful shoulder 4 years after a Bristow procedure. Radiographic imaging confirmed contact of the humeral head on the Bristow screw. In these unusual situations, arthroscopic evaluation, as this case suggests, should be considered. The patient's hardware was removed arthroscopically, obviating an open procedure and hospitalization.
Meniscal repair, healing, and survival have been demonstrated in the literature. Meniscal preservation is, however, not always possible. We present a technique that may aid the surgeon in difficult bucket handle resections by stabilizing a portion of the meniscus with a "suture retractor" prior to resecting either a posterior or anterior meniscal horn. This technique may also be modified to prepare the inner rim when one is performing meniscal repair.
A technical recommendation of primarily bone grafting the patellar tendon graft site created following harvesting the central third of the free bone-tendon-bone patellar tendon graft for anterior cruciate ligament (ACL) insufficiency is presented. Harvesting a patellar bone-tendon-bone graft produces a stress riser that increases the potential risk of a patellar fracture. Primary bone grafting of the patellar region is recommended as a simple and safe solution, especially if a graft wider than 10-12 mm or deeper than 6 mm is taken. We feel that this will reduce even further the small likelihood of late patellar fracture. Using these principles, we have not had any late patellar fractures in over 135 consecutive ACL reconstructions since July, 1986.
Triceps brachii injuries are uncommon, resulting from indirect or direct trauma generally associated with an eccentric contraction. The tendo-osseous junction is the most common location. An extensor lag and palpable gap are diagnostic of complete rupture. Diminished extension strength against resistance implies a partial triceps rupture. A radiograph must be obtained as triceps ruptures are associated with olecranon or radial head fractures. A lateral radiograph may reveal an avulsion or 'flake' fracture. Early surgical repair of complete tendon ruptures is recommended. Surgical results are generally excellent.
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Few complications from tenodesis of the long head of the biceps brachii have been described despite the wide variety of techniques. In a 53-year-old man, rupture of this tendon was treated by tenodesis and was complicated by heterotopic ossification that severely limited the function of the shoulder joints. Nonsurgical conservative treatment of biceps tendon ruptures may avoid the possibility of this complication.
We used the KT-1000 arthrometer to test the knees of 107 patients who had an acute tear of the anterior cruciate ligament, 153 patients who had a chronic tear, and 141 control subjects, for a total of 401 individuals. The three testing parameters were the extent of anterior translation at eighty-nine newtons of force and at maximum manual force, and the compliance index. The differences between the involved and the uninvolved knees were calculated. At eighty-nine newtons, all but one of the control subjects had anterior translation of ten millimeters or less, compared with 58 per cent of the patients who had a chronic tear. At maximum manual force, all but two of the control subjects had translation of ten millimeters or less, compared with 20 per cent of the patients who had an acute or a chronic tear. Analysis of variance showed that the clinical diagnosis correlated well with the results for all tests (p less than 0.001). However, when the uninjured knees of patients who had an acute or a chronic tear were compared with the knees of the control subjects, significant differences were noted (p less than 0.001 to 0.006). In the patients who had a chronic tear, there was no relationship between the time from injury to operation and the extent of anterior translation. The arthrometric test at maximum manual force was the strongest discriminant; it differentiated normal from abnormal knees (p less than 0.001) with high sensitivity (92 per cent), high specificity (95 per cent), and high positive predictive accuracy; the cut-off point was eleven millimeters or less.(ABSTRACT TRUNCATED AT 250 WORDS)
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Sixteen patients who had unilateral deficiency of the anterior cruciate ligament and ten healthy control subjects were analyzed during level walking, jogging, and ascending and descending stairs. Kinematic and kinetic findings for the right and left hips, knees, and ankles of all of the patients and control subjects were recorded during each activity. Substantial differences from normal function were observed for both limbs of the patients during level walking and during jogging. The magnitude of the maximum moment that tended to flex the knee was reduced the most (140 per cent) during level walking. It was reduced less (30 per cent) during jogging, it was not changed while the patient descended stairs, and it was slightly increased while he or she ascended stairs. The reduction in the magnitude of the flexion moment about the knee was interpreted as the patient's effort to reduce or avoid contraction of the quadriceps. Reduction of the flexion moment reduces any contraction of the quadriceps because there must be a mechanical balance between the external moment (due to body weight and the weight and inertia of the segment of the limb) that tends to flex the knee and an internal moment (generated by contraction of the quadriceps) that tends to extend the knee. This so-called quadriceps-avoidance gait was related to the angle of flexion of the knee when the maximum flexion moment occurred during each activity. This angle of flexion was 20 degrees during walking, 40 degrees during jogging, and approximately 60 degrees during stair-climbing.(ABSTRACT TRUNCATED AT 250 WORDS)