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The authors present a new surgical approach to the medical condition that is known as enthesiopathy of the tendo Achillis. The cases presented demonstrate a surgical technique that addresses the calcified Achilles tendon at its insertion, without weakening the insertion fibers. This technique allows bone-to-bone healing instead of tenodesis and significantly reduces the likelihood of a ruptured tendo Achillis.
Resection of the ulna is an effective operation in the treatment of rheumatoid disorders of the distal radioulnar joint. Tenosynovectomies of the overlying extensor tendons and synovectomy of the joint are integral parts of the procedure. Following resection, the ulna usually remains in alignment with the radius, although some dorsal displacement is common. Restoring stability to the ulna as well as reconstructing a new sheath for the extensor carpi ulnaris can be accomplished in most cases by using the extensor retinaculum. In those cases where the retinaculum has been destroyed by the disease process or when the distal ulna is severely displaced, stability can be restored using the extensor carpi ulnaris for a tenodesis.
A retrospective review was conducted of 112 active-duty military patients receiving anterior cruciate ligament reconstruction between 1985 and 1987. Mean age of these patients was 26.4 years, average follow-up was 2.35 years, and the average interval from time of injury to reconstruction was 13.6 months. The three most commonly employed surgical techniques were the Andrews' iliotibial band tenodesis, mid-third patellar tendon autograft, and a combined Andrews' and mid-third patellar tendon reconstruction. Seventy-eight patients (69.6%) returned to full duty and the ultimate disposition was not affected by the reconstructive procedure performed, chronicity of injury, or sex. A statistically higher percentage of patients over 30 years old returned to full unrestricted military service than did patients under 30. Associated posterior cruciate injury and degenerative joint disease resulted in poorer results. Our results demonstrate that functional restoration, based on the occupational criteria of return to full unrestricted duty, is likely following anterior cruciate ligament reconstruction.
A study was performed on the effect of the addition of an extra-articular procedure involving tenodesis of the iliotibial band to a reconstruction with a bone-patellar ligament-bone allograft for the treatment of chronic rupture of the anterior cruciate ligament. One hundred and four patients were divided into two groups for comparison: Group 1 (sixty-four patients) was treated with only an intra-articular replacement with an allograft and Group 2 (forty patients), with both an intra-articular replacement with an allograft and the extra-articular procedure. Preoperatively, there were no statistically significant differences between the two groups in terms of twenty variables, including body weight, level of activity, anterior-posterior displacements, number of previous operations, and duration of follow-up. All of the patients returned for follow-up evaluation twenty-three to fifty-four months (mean, thirty-five months) postoperatively. All were treated with the same postoperative program of immediate motion of the knee and rehabilitation. The results were evaluated with the use of a comprehensive subjective and objective system that rated the twenty factors. Both procedures proved to be effective in decreasing functional limitations and symptoms and in improving the level of sports activity and the over-all scores. The results in Group 2 were significantly better than those in Group 1, as measured with tests done with the KT-1000 arthrometer (p less than 0.01) and with regard to the level of sports activity (p less than 0.05) and the over-all scores (p less than 0.01). There was no postoperative difference between the two groups in terms of the results on pivot-shift or isokinetic testing, patellofemoral crepitus, functional limitations, or symptoms. The program of rehabilitation effectively restored 0 to 135 degrees of motion to all but four knees, which lacked 5 degrees of extension at the most recent follow-up. The over-all rate of failure for both groups was 11 per cent. However, the rate of failure was 16 per cent (ten of sixty-four knees) in Group 1 and only 3 per cent (one of forty knees) in Group 2. This difference was significant (p less than 0.05). The extra-articular procedure appeared to provide support to the healing intra-articular allograft by reducing deleterious forces and tibial displacements, and to restore the secondary restraints provided by the lateral iliotibial band. The results suggest that the combination of the procedures is of value in young, athletically active people who have chronic rupture of the anterior cruciate ligament.(ABSTRACT TRUNCATED AT 400 WORDS)
193 fingers of 131 patients have been treated at the level of the I, II and III zones due to inveterate tendon damages. In case of isolated damage of deep flexor tendon of the II-V fingers at the level of the I zone there were made palliative operations of 12 fingers: tenodesis and arthrodesis of distal interphalangeal articulation in functionally advantageous position. They failed to achieve successful outcome with one finger. In 17 cases long flexor tendon of the I finger had been restored by different methods; in all cases there were achieved good and excellent outcomes. Three fingers (IV, V) with the tendon, damaged at the II zone level, were subjected to plasty by free autotransplant. The outcomes are as follows; satisfactory--2, bad--I. At the remaining 161 finger (II-V) deep flexor tendon has been restored by different methods with utilization of autotendon with its natural blood circulation or revascularized one. There was formed an artificial tendon sheath in some methods. Positive outcomes, as evaluated by the system of the American association of hand surgeons, were achieved in 138 (85.7%) cases, by Buch-Gramcko system--in 143 (88.8%) cases.
On the basis of analysis of the roentgen contrast examination of femoral muscles of the patients with extension contractures of knee joint, roentgen systematics of the muscle changes at given pathology is presented and the criteria of differential diagnosis of contractures of different types are proposed. 55 patients (125 examinations) with extension contractures of knee joint (arthrogenic, immobilizing, due to myofascio-tenodesis) of different etiology were subjected to roentgen contrast myography. As a consequence, this offered a means of objective evaluation of the muscle state and enabled one to discover the changes of muscles, specific for contractures in general as well as for each type in particular. The table of roentgenologic signs has been compiled which permits to make differential diagnosis, determine the tactics of treatment, select the type of surgical intervention on the basis of the muscle condition.
The primary suture was put in 40 patients with 55 injuries of the tendons. The study of the long-term results of the treatment after putting the primary suture on 40 tendons of the flexors of the fingers of the hand has shown that in 21 patients who were put the sutures proposed by the authors there were excellent and good results in 90.4% of the cases. When classical sutures were put and the fingers were immobilized after the operation in 19 patients, the results were excellent and good in 84.3% of the cases, which was mostly at the expense of tenodesis effect in the distal interphalangeal joint.
Between 1975 and 1979, anterior acromioplasty was performed in 65 patients with 66 involved shoulders. The procedure appears to be safe and reasonably effective. Of the 65 patients in this study, 50 had chronic tendon inflammation with fibrosis, and 16 also had a small supraspinatus tendon tear. These 16 had rotator cuff repairs. Twenty-six patients were also treated with distal clavicle excision, and seven had tenodesis of the long head of the biceps brachii. The average age of the patients was 50 years (range, 23-75 years). All patients were followed for an average of eight years (range, three to 13 years). At final evaluation, no or slight pain was present in 77% of the shoulders: 39 of 50 without tendon tearing and 12 of 16 with tendon tearing and repair. Active shoulder abduction averaged 167 degrees. Ninety-two percent returned to employment, including 18% with some job modification. Eighty-six percent returned to recreational athletics, 20% with some modification of activities. Seven patients had additional surgical treatment. The progression of rotator cuff disease is not always prevented, but the need for subsequent shoulder treatment generally decreases.
After an inadequate conservative treatment of III-grade sprain of the ankle combined with the rupture of ligaments, these heal in prolongation which result in the chronic instability of the ankle joint. After the evaluation of the anamnesis and the objective examination the diagnosis is specified by comparative forced X-ray images in both projections. To substitute insufficient fibular ligaments we use a modification of the Weber method. We perform tenodesis of m. peronaeus brevis. The tendon is led through the bone channel above the apex of the lateral maleolus and its proximal end is fixed in the area of the origin of lig. fibulotalare anterius to talus. We checked up 29 patients on average 4 years and 7 months after the operation. From the subjective viewpoint almost 80 per cent patients had no or minimum complaints. In the examination of the range-of-motion; we found in 52 per cent of patients the range identical with the intact side, in 41 per cent there occurred functionally insignificant limitation of inversion. On the basis of longterm satisfactory results we can recommend our modification of the Weber method as a simple and efficient method of the treatment of chronical instability of the ankle joint.
The authors present the results of 13 cases operated for subcutaneous rupture of the extensor pollicis longus. Transferral of the extensor indicis proprius was employed in 12 cases and tenodesis involving the extensor pollicis brevis was performed in 1. Results are best when abduction and retropulsion of the thumb are restored. Testing of the correct tension of the transferral procedure is emphasized.
The notoriously limited capacity of articular cartilage to heal or to regenerate plus the author's clinical observations and research on the deleterious effects of immobilization on joints led him to the biologic concept of continuous passive motion (CPM) of synovial joints in 1970. The hypothesis that CPM should stimulate pluripotential mesenchymal cells to differentiate into articular cartilage and should accelerate the healing of articular tissues has been validated by numerous scientific investigations of a variety of experimental models of the knee joint. These models have included full-thickness defects, intraarticular fractures, acute septic arthritis, partial thickness lacerations of the patellar tendon, semitendinosus tenodesis to replace the medial collateral ligament, autogeneic osteoperiosteal grafts in major defects, free autogeneic periosteal grafts, and periosteal allografts. In 1978, the author collaborated with Saringer, an engineer, to develop CPM devices for humans. CPM is clinically indicated following such procedures as open reduction of fractures, arthrolysis for posttraumatic arthritis, synovectomy, drainage of septic arthritis, release of joint contractures, total arthroplasty, tendon repair, and ligament reconstruction. Clinically, CPM is an important stimulus to joint regeneration processes.
It is important to evaluate each swan-neck deformity to determine the mobility and radiographic condition of the PIP joint. This information forms a basis for logical treatment. In those fingers with little or no loss of motion, the treatment alternatives include DIP joint fusions, dermadesis, or flexor tenodesis. With significant loss of PIP joint motion, an attempt is made to first restore passive motion by manipulation and lateral band or skin releases. It then becomes essential to restore flexor tendon excursion. In those patients with destroyed joint surfaces the salvage procedures of fusion and arthroplasty are the treatments of choice.
The indications and results of anterior acromioplasty in patients older than 40 years of age are well documented; however, little is reported concerning this procedure in younger patients because the majority are treated conservatively. Over the last seven years, 26 patients younger than 40 years of age were treated by anterior acromioplasty for subacromial impingement resistant to conservative therapy. The indication for surgery was failed conservative therapy in 17 patients. Six patients had impingement despite previous surgery, such as failed acromioplasty, biceps tenolysis, and biceps tenodesis. Two patients had impingement secondary to greater tuberosity malunion. The average duration of symptoms was 27 months and of conservative therapy, 17 months. All patients had a bursectomy and anterior acromioplasty. In addition, eight had a complete acromioclavicular arthroplasty for concurrent acromioclavicular arthritis, four had a modified acromioclavicular arthroplasty for impingement under the acromioclavicular joint, three had calcium excisions, and one had a rotator cuff repair. The greater tuberosity malunions were advanced in one patient and excised in one. The results were 81% (21) excellent and good, 15% (four) fair, and 4% (one) poor. The average follow-up period was 33 months. The majority of younger patients with subacromial impingement can be successfully treated conservatively. In those patients with persistent symptoms, open acromioplasty can reliably give good results with regard to pain and function.
The findings at clinical and roentgenological follow-up examination of 44 patients are reported to illustrate the long-term results of a modified Watson-Jones technique up to 90 months after the operation. The clinical results (86.3% of the patients without complaints and 88.6% with subjective stability of the ligaments) correspond with those given by a variety of sources in the literature. The roentgenological examination, on the other hand, showed signs of grade I or II arthrosis (Bargon scale) in 61.3% of cases, and arthrosis was worse than before the operation in nearly all cases. The patients in the group, that had received more conservative treatment with an average 6.3 years between lesion and surgical treatment (group 1), had the highest incidence of arthrosis, with 73.6%. In 10 cases the clinical examination revealed reduced supination and dorsiflexion attributable to the tenodesis effect associated with the Watson-Jones technique. In view of the high rate of arthrosis, younger patients and patients with a short tendon part of the peroneus brevis muscle should be treated by another, more "physiological" method.
The metacarpophalangeal joint of the thumb has less range of motion than any other digital joint. Its stability is more important than its mobility. Thus, arthrodesis of this joint causes relatively little loss of function, provided only that the joint is fused in the correct position. The authors reviewed all MP joint fusions of the thumb which were done at their hospital between 1974 and 1985. They examined individually forty-one of the fifty patients and studied the indications, surgical techniques and difficulties, and the complications. Furthermore, they measured all angles of fusion and concluded that the optimal position is fifteen degrees of flexion and ten degrees of pronation. The use of tension band wiring facilitates the achievement and maintenance of the desired position. The stability of the fusion permits exercise immediately after the operation; this helps to avoid a tenodesis of the long extensor tendon of the thumb.
Spasticity that interferes with upper extremity function is common in adults following stroke, brain injury, or anoxia. During the period of neurologic recovery definitive surgical procedures are avoided. Techniques to temporarily reduce spasticity include the implantation of a MicroPort reservoir and catheter for repeated branchial plexus blocks and phenol nerve blocks, which provide longer lasting relief of noxious muscle tone. Percutaneous blocks of the musculocutaneous and recurrent median nerves and motor point blocks of the pectoralis major, the brachioradialis, and forearm flexor muscles are easily performed at bedside. The motor branch of the ulnar nerve can be injected surgically with phenol to diminish intrinsic spasticity. When neurologic recovery has plateaued, hand placement can be improved in many patients following proximal release of the brachioradialis muscle and lengthening of the biceps and branchialis tendons. Hand function is enhanced by fractional lengthening of spastic wrist and finger flexors. Intrinsic spasticity must be addressed at the same time by phenol block or intrinic release. When extensor function is lacking, a tenodesis of the wrist extensors is helpful. The thumb-in-palm deformity requires proximal release of the thenar muscles as well as lengthening of the flexor pollicis longus. Contracture releases in the nonfunctional arm improve hygiene and ease care.
The aponeurosis of the common extensor tendons is connected by intertendinous connections proximal to the metacarpophalangeal joints. These fibers are responsible for tenodesis effects in case of maximal finger extension and flexion and by this means they diminish the function of the other metacarpophalangeal joints. This mechanism can be described as the Quadriga-Syndrome of the extensor apparatus. These connecting structures also help to stabilize the transverse metacarpophalangeal arch and the position of the extensor tendons over the metacarpal heads. Cadaver dissections as well as operative findings have shown that there exists a superficial transverse intermetacarpal ligament, which connects the metacarpal heads in the area of its neck.
Since 1972, the author has performed 259 brachial plexus repairs and various associated secondary procedures. The best results were obtained with surgery delayed four to five weeks, because the preoperative assessment of the lesion is more accurate after wallerian degeneration has occurred. In addition, formation of a proximal neuroma allows definition of the exact limits for resection. In cases with associated vascular damage, the vessels should be repaired at the same time as the nerve grafts unless there is severe ischemia. Intraspinal exploration with cervical laminectomy is not justified because intraspinal avulsion is always due to rootlet avulsion. Division of the clavicle to facilitate exploration of the anatomy of the plexus where it is the most complex is advocated. In general, distal grafting allows the recovery of a single function, which is preferable to an attempt at total anatomic repair. The adverse effects of contractions must be avoided. The priority of restoration of functions is an important consideration. Elbow flexion should be the first priority, followed by wrist extension, finger flexion, and shoulder abduction, in that order. The results of grafting may be improved by ancillary operations such as shoulder fusion, flexor tendon tenodesis, humeral derotation, and other procedures that provide limited function for patients with various incomplete and complete avulsions. Microsurgical repairs of brachial plexus lesions currently offer the best results for patients with this type of injury.