Current methods for the evaluation of ankle ligament injuries.
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Ankle Injuries↗
Biomedical subjects
R A Marder
Publications and source records attributed to R A Marder.
The entire rotator cuff contributes to elevation of the arm.
The function of the infraspinatus, teres minor, and subscapularis during elevation of the arm remains poorly defined. These muscles may generate moments that contribute to abduction of the arm, although they frequently are classified as humeral depressors. The purposes of this study were to measure the contributions to abduction made by the more inferiorly positioned rotator cuff muscles relative to the contributions of the supraspinatus and to determine the range of motion at which the muscles are most effective. Five fresh cadaveric shoulder girdles were mounted in an apparatus designed to simulate contraction of the deltoid and rotator cuff while maintaining the normal relationship between glenohumeral and scapulothoracic motions. The deltoid force required for elevation was measured without simulated contraction of the rotator cuff and with simulated contraction of the entire rotator cuff, of the supraspinatus only, and of the infraspinatus-teres minor and subscapularis only. A significant reduction in deltoid force when other muscle activity was added indicated that the additions contributed significantly to abduction. The deltoid force required with concurrent contraction of the entire rotator cuff averaged 41% less than with the deltoid alone but was not significantly different than with the deltoid and supraspinatus or with the deltoid, infraspinatus-teres minor, and subscapularis. Concurrent application of forces to the supraspinatus or the infraspinatus-teres minor and subscapularis significantly reduced the required deltoid force over the range of motion studied by an average of 28 and 36%, respectively. The contributions of the rotator cuff muscles to abduction of the arm were greatest at low abduction angles (30 and 60 degrees) and were insignificant by 120 degrees. The infraspinatus-teres minor and subscapularis contribute significantly to abduction: their contribution was equal to that of the supraspinatus and, like the supraspinatus, they are most effective during the first 90 degrees of abduction.
Aged↗
Ankle dislocation.
From 1980 to 1991, 14 patients with pure ankle dislocation unassociated with fracture were identified. All patients were young adults (18-41 years of age) with a male preponderance (11 of 14). The cause of injury in nine of the 14 cases was a motor vehicle accident and in the remainder, sporting events or fall from a height. Thirteen of the 14 injuries were open, and 12 patients underwent lateral ligamentous repair. Twelve of the 14 patients were available for follow-up, which ranged from 15 to 122 months. Two patients had poor results; the remainder (10 of 12) had good and excellent results. Interestingly, no patient had signs or symptoms of instability. One patient required immediate below-the-knee amputation for open dislocation associated with avulsion of soft tissue and neurovascular structures.
Adolescent↗
Effects of partial patellectomy and reattachment of the patellar tendon on patellofemoral contact areas and pressures.
We used a previously reported experimental method to measure patellofemoral contact areas and pressures in four pairs of human cadaveric knees before and after a partial patellectomy. The knee joints were loaded by application of a flexion moment, which was resisted by the extension moment of the quadriceps mechanism. Patellofemoral contact was measured with the use of pressure-sensitive film, at 30, 60, and 90 degrees of flexion of the knee. Partial patellectomy decreased the patellofemoral contact area and increased pressure. We observed alterations in the patterns of contact, including a proximal shift in patellofemoral contact, after partial patellectomy. An anterior reattachment of the patellar tendon significantly minimized the effects of 20 and 40 per cent patellectomies (p < 0.05). After a 60 per cent patellectomy, patellofemoral contact was altered markedly, with the contact area reduced to less than 50 per cent of the control values regardless of the position of the patellar tendon reattachment.
Adult↗
Arthroscopic versus open debridement of penetrating knee joint injuries.
Arthroscopic debridement of penetrating knee joint injuries has become a common treatment method. A comparative study was undertaken to compare this method with open joint debridement. Fourteen penetrating knee joint injuries (fourteen patients) were treated by arthroscopic examination and debridement and were compared to sixteen penetrating knee joint injuries (fifteen patients) treated by open debridement. There were no resultant infections or operative complications in either group. Of note, the arthroscopic debridement group had a shorter postoperative hospital stay [mean of 1.6 days compared to a mean of 2.6 days in the open debridement group (p < 0.02)], a significant incidence of additional intra-articular injuries detected (p < 0.01), less postoperative pain, and a superior cosmetic result. We conclude that arthroscopic debridement of penetrating knee joint injuries is a safe and effective method of treatment, providing additional diagnostic information while minimizing morbidity and reducing hospital stay.
Adolescent↗
Arthroscopic-assisted reconstruction of the anterior cruciate ligament.
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Arthroscopy↗
Principles of management of fractures in sports.
Return to athletic activity following a traumatic fracture most frequently requires normal anatomic and functional restoration of the extremity. Treatment of the skeletal injury should follow sound biomechanical principles allowing early soft-tissue rehabilitation. Familiarity with both closed functional treatment methods, as well as operative techniques, is required. Early detection and treatment of possible complications and institution of a comprehensive plan for rehabilitation and reconditioning can improve the chances for a successful outcome.
Athletic Injuries↗
Injuries of the knee associated with fractures of the tibial shaft. Detection by examination under anesthesia: a prospective study.
Ligamentous injuries of the ipsilateral knee have been documented in association with 25 to 35 percent of fractures of the femoral shaft. However, to our knowledge, a similar association between ligamentous injuries of the knee and fracture of the tibial shaft has not been studied prospectively. To determine if there was such an association, a prospective study was conducted in which the knees of fifty patients who had a fracture of the ipsilateral tibial shaft of varying severity were examined manually while the patient was under general anesthesia. Eleven patients (22 percent) were found to have sustained an injury to at least one ligament of the knee that resulted in increased laxity of 2+ or more. One knee had dislocated. On the basis of the results of this study, we believe that, after stabilization of a fracture of the tibial shaft, it is essential to examine the knee thoroughly to identify any associated ligamentous injuries.
Adolescent↗
Open intramedullary nailing and bone-grafting for non-union of tibial diaphyseal fracture.
Twenty consecutive patients who had non-union of twenty-two fractures (two of the patients had a segmental fracture) of the tibia underwent open reduction, débridement, and intramedullary nailing that was supplemented by bone-grafting with either autogenous cancellous iliac bone or cortical reamings of bone from the intramedullary canal. Eighteen patients had significant deformity associated with the tibial fracture. All but three patients had postoperative splinting for two to four weeks, followed by walking without a brace; the three patients who did not have postoperative splinting were more than sixty-five years old. All of the fractures went on to union. Two patients had a minor complication that did not affect the final result. Incorporation of callus across the site of non-union occurred at a rapid rate. Anatomical alignment of the tibial shaft was obtained in nineteen of the twenty patients.
Adolescent↗
The pathology of failed total joint arthroplasty.
In 94 cases of failed total hip and knee joint arthroplasties, acute and chronic inflammation, acrylic, metal, and polyethylene debris, and histiocytic reaction were assessed in a 0, 1+, 2+, 3+ semiquantitative manner. Chronic inflammation of 2+ to 3+ was not particularly useful in separating a reaction to wear debris from infection. At the time of frozen section, 2+ to 3+ acute inflammation (greater than 5 PMNs per high power field) was used with excellent follow-up bacteriologic correlation to delay replacement of the failed prosthesis until the infection was controlled. Acrylic (2+ to 3+) and excessive polyethylene wear debris correlated well with loosening. Dusky grey cells were the hallmark of metal-filled histiocytes. Mononuclear and multinuclear histiocytes (2+ to 3+) were correlated with excessive acrylic and/or polyethylene debris. The histologic features of metal particles, acrylic voids, polyethylene and teflon fibers and silastic globules illustrate the pathologic identification of these materials.
Acrylic Resins↗
Early morbidity after total hip replacement: rheumatoid arthritis versus osteoarthritis.
The authors used the California Health Facilities Discharge data for 1984 and 1985 to compare retrospectively in-hospital morbidity and mortality of all 721 patients with rheumatoid arthritis versus all 8,859 patients with osteoarthritis who underwent a non-emergent, first-time, unilateral total hip arthroplasty. The lengths of hospitalization, in-hospital mortality rates, and incidences of postoperative complications were similar in the two groups except for higher rates of wound infection and wound dehiscence in the patients with rheumatoid arthritis and a higher rate of thromboembolic events in the osteoarthritis group. The short-term outcome of patients with rheumatoid arthritis appears comparable to that of patients with osteoarthritis.
Aged↗
Strain measurement in lateral ankle ligaments.
We measured strain in the lateral ligaments of 10 human cadaver ankles while moving the ankle joint and applying stress in a variety of ways. We studied the anterior talofibular, calcaneofibular, posterior talofibular, anterior tibiofibular, and posterior tibiofibular ligaments. Strain measurements in the ligaments were recorded continuously while the ankle was moved from dorsiflexion into plantar flexion. We then repeated measurements while applying inversion, eversion, internal rotation, and external rotation forces. Strain in the anterior talofibular ligament increased when the ankle was moved into greater degrees of plantar flexion, internal rotation, and inversion. Strain in the calcaneofibular ligament increased as the talus was dorsiflexed and inverted. These findings support the concept that the anterior talofibular and calcaneofibular ligaments function together at all positions of ankle flexion to provide lateral ankle stability. We measured maximum strain in the posterior talofibular ligament when the ankle was dorsiflexed and externally rotated. The strain in the anterior and posterior tibiofibular ligaments increased when the ankle was dorsiflexed. External rotation increased strain in the anterior tibiofibular ligament and decreased strain in the posterior tibiofibular ligament. Based upon strain measurements in the lateral ankle ligaments in various ankle joint positions, we believe the anterior talofibular ligament is most likely to tear if the ankle is inverted in plantar flexion and internally rotated. Theoretically, the calcaneofibular ligament tears primarily in inversion if the ankle is dorsiflexed; the anterior tibiofibular ligament tears in dorsiflexion, especially if combined with external rotation; and the posterior tibiofibular ligament tears with extreme dorsiflexion.
Adult↗
Prospective evaluation of arthroscopically assisted anterior cruciate ligament reconstruction. Patellar tendon versus semitendinosus and gracilis tendons.
Eighty consecutive patients with chronic laxity due to a torn ACL underwent arthroscopically assisted reconstruction with either autogenous patellar tendon or doubled semitendinosus and gracilis tendons. Reconstructions were performed on a one-to-one alternating basis. Preoperatively, no significant differences between the two groups were noted with respect to age, sex, level of activity, and degree of laxity (chi square analysis). A standard rehabilitation regimen was used for all patients after surgery including immediate passive knee extension, early stationary cycling, protected weightbearing for 6 weeks, avoidance of resisted terminal knee extension until 6 months, and return to activity at 10 to 12 months postoperatively. Seventy-two patients were evaluated at a minimum of 24 months postoperatively (range, 24 to 40 months). No significant differences were noted between groups with respect to subjective complaints, functional level, or objective laxity evaluation, including KT-1000 measurements. Seventeen of 72 patients (24%) experienced anterior knee pain after ACL reconstruction. Overall, 46 of 72 patients (64%) returned to their preinjury level of activity. Mean KT-1000 scores were 1.6 +/- 1.4 mm for the patellar tendon group and 1.9 +/- 1.3 mm for the semitendinosus and gracilis tendons group. This study did find a statistically significant weakness in peak hamstrings torque at 60 deg/sec when reconstruction was performed with double-looped semitendinosus and gracilis tendons.
Adolescent↗
Reconstruction of the lateral ankle ligaments. A biomechanical analysis.
UNLABELLED: The purpose of this study was to perform a biomechanical analysis of several commonly performed operative procedures used to stabilize the lateral ankle. We performed the Evans, Watson-Jones, and Chrisman-Snook procedures on 15 cadaveric ankles and tested the ankles for stability, motion, and isometry of graft placement. The Evans procedure allowed increased anterior displacement, internal rotation, and tilt of the talus when compared to ankles with intact ligaments. Subtalar joint motion was restricted by the Evans procedure. The Watson-Jones procedure controlled internal rotation and anterior displacement of the talus, but was less effective in controlling talar tilt and also restricted subtalar joint motion. The Chrisman-Snook procedure allowed increased internal rotation and anterior displacement of the talus when compared to ankles with intact ligaments. The procedure was effective in limiting talar tilt, but restricted subtalar joint motion. Based on the biomechanical data obtained, we devised a lateral ankle reconstruction with bone tunnels that reproduce the anatomic orientation of both the anterior talofibular and calcaneofibular ligaments. This ankle ligament reconstruction resists anterior displacement, internal rotation, and talar tilt without restricting subtalar joint motion. CLINICAL RELEVANCE: We found considerable mechanical differences among the more commonly performed lateral ankle reconstructions. It is possible to locate bone tunnels and graft placement so that a more anatomic configuration is achieved.
Adult↗
The rotator cuff opposes superior translation of the humeral head.
To determine the influence of rotator cuff muscle activity on humeral head migration relative to the glenoid during active arm elevation we studied five fresh cadaveric shoulders. The shoulder girdles were mounted in an apparatus that simulated contraction of the deltoid and rotator cuff muscles while maintaining the normal scapulothoracic relationship. The arms were abducted using four different configurations of simulated muscle activity: deltoid alone; deltoid and supraspinatus; deltoid, infraspinatus, teres minor, and subscapularis; and deltoid, supraspinatus, infraspinatus, teres minor, and subscapularis. For each simulated muscle configuration the vertical position of the humeral head in relation to the glenoid was determined at 30 degrees, 60 degrees, 90 degrees, and 120 degrees of abduction using digitized anteroposterior radiographs. Both muscle activity and abduction angle significantly influenced the glenohumeral relationship. With simulated activity of the entire rotator cuff, the geometric center of the humeral head was centered in the glenoid at 30 degrees but had moved 1.5 mm superiorly by 120 degrees. Abduction without the subscapularis, infraspinatus, and teres minor muscles caused significant superiorly directed shifts in humeral head position as did abduction using only the deltoid muscle. These results support the possible use of selective strengthening exercises for the infraspinatus, teres minor, and subscapularis muscles in treatment of the impingement syndrome.
Aged↗