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PubMed1986

Popliteal artery injuries: civilian experience with sixty-three patients during a twenty-four year period (1960 through 1984).

Our experience with 63 patients who had popliteal artery injuries sustained in civilian accidents is reported. Blunt injuries occurred in 53 patients and 49 had associated skeletal injuries. Eighteen patients suffered knee dislocation; six of these patients had associated fractures. Fractures of the upper third of the tibia occurred in 21 patients. Five patients had irreversible ischemia and required primary amputation. Thirteen amputations were required in 58 patients in whom arterial repair was performed, for an amputation rate of 22%. There were no amputations in 19 patients treated less than 6 hours after injury was sustained. Four deaths occurred. Fasciotomy was performed in 20 patients. Skeletal injuries were usually treated with external fixation.

Adolescent↗
PubMedDate not supplied

Knee angles and rickets in nigerian children.

Knee angles of 2,036 normal Nigerian children up to 12 years old were measured directly or from photographs. The knees were bowed (varus) in the first 6 months. At 21 to 23 months, the distribution of angles became strongly bimodal: about half were varus and half were valgus (knock-kneed), with few in between. After this they were all valgus, with few exceptions. Hence, the change from varus to valgus in individual infants must be sudden (a few weeks), although the changeover of the whole population appears smooth and gradual. They became maximally and uniformly knock-kneed (-7.1 degrees +/- 1.4 degrees) between 3 and 3.5 years, with little change thereafter. On the other hand, 120 patients with rickets discovered during screening had large knee angles, in either sense, with a bimodal distribution and frequency maxima at +10 degrees (varus) and -12 degrees (valgus). Varus knee is uncommon after 2 years. Large knee angles between 2 and 5 years suggest rickets.

Age Factors↗
PubMed1983

Improved limb salvage in popliteal artery injuries.

This study reviews the recent experience with popliteal artery injuries at the Massachusetts General Hospital. Twenty-two patients suffered 24 injuries. The overall limb salvage was 83%. Blunt trauma accounted for 19 of the cases and was associated with femur fractures, knee dislocations, and tibia-fibular and plateau fractures: four amputations (21%) resulted. There were five penetrating injuries from three gunshot wounds, one stab wound, and one laceration: no amputations occurred. The major factor in the amputated limbs was delay in diagnosis and therapy of the arterial injury associated with blunt trauma. Arterial disruption secondary to penetrating injuries was recognized more quickly and had a better outcome. A higher index of suspicion in blunt trauma may improve results. Recommendations for therapy are: arterial reconstruction should generally precede orthopedic operation. Venous ligation was not associated with increased limb loss, but we recommend repair if possible. Arterial repair includes thrombo-embolectomy in distal arteries. If necessary, reverse saphenous vein is grafted. When operation is unsuccessful, revision should be performed.

Adolescent↗
PubMed1994

The clinical features of Ehlers-Danlos syndrome type VIIB resulting from a base substitution at the splice acceptor site of intron 5 of the COL1A2 gene.

The features of a 32 year old woman with Ehlers-Danlos syndrome type VIIB and affected members of her family, resulting from a mutation in one COL1A2 allele, were studied. Her dermal type I collagen contained alpha 2(I) chains and mutant pN-alpha 2(I) chains in which the amino-terminal propeptide remained attached to the alpha 2(I) chain. She was heterozygous for an AG-->AC mutation at the splice acceptor site of intron 5 of the COL1A2 gene. The mutation activated a cryptic AG splice acceptor site corresponding to positions +14 and +15 of exon 6 of the COL1A2 gene. In contrast to previous reports only five, rather than all 18, amino acids encoded by exon 6 were deleted in the proband. The deleted peptide removed the amino-proteinase cleavage site, but not the nearby lysine cross linking site in the amino-telopeptide of the alpha 2(I) chain. She was born with bilateral hip dislocations, knee subluxations, and generalised joint hypermobility. Bilateral inguinal herniae and an umbilical hernia were present at birth. Facial features included a depressed nasal bridge with prominent paranasal folds. The skin was soft, moderately hyperelastic, and sagged over the face. Skin fragility and easy bruising were apparent from childhood. Skin wounds healed slowly and with broad, paper thin scars. Throughout her life, she had multiple fractures of the small bones of her hands and feet following moderate trauma. Electron microscopy of the proband's dermis as well as deep fascia and hip joint capsule from her affected brother showed that collagen fibrils in transverse section were nearly circular but with irregular margins. Light microscopy of bone from her affected brother and son showed normal Haversian systems and lamellar bone. All of these tissues contained approximately equal amounts of the normal and mutant alpha2(I) chains. The findings of this study confirm that loss of the amino-proteinase cleavage site of the pro alpha2(I) collagen chains, owing to anomalous splicing of exon 6 sequences in the conversion of pre-mRNA to mRNA, produces the clinical features of Ehlers-Danlos syndrome type VIIB. The history of frequent fractures found in this family is atypical and indicates an overlap with osteogenesis imperfecta.

Adult↗
PubMed1991

Lengthening for congenital short femur. Results of different methods.

We have reviewed the results in 37 patients with unilateral congenital short femur (Pappas classes III to IX), treated by different lengthening procedures. The increase in the length of the femur varied from 15.6% to 142%, excellent or good results being obtained in 32 patients (86%). There was an average of 1.9 complications per case, most being seen earlier in the series when the Wagner technique was used. With the Orthofix and the Ilizarov techniques, we used callus distraction in all cases. We found that the proximal diaphysis of the congenitally abnormal femur healed less well, and we now prefer to perform corticotomy and callus distraction of the distal metaphysis. The Ilizarov method gave the best results, offering the possibilities of the simultaneous use of a Hoffmann fixator across the hip and the treatment of knee dislocation and instability.

Adolescent↗
PubMed2004

Knee stability following anterior cruciate ligament rupture and surgery. The contribution of irreducible tibial subluxation.

BACKGROUND: Knee stability after anterior cruciate ligament reconstruction is generally determined by measuring total anteroposterior tibial motion. In spite of a decrease in excessive anteroposterior tibial motion after anterior cruciate ligament reconstruction, problems can still develop. In the present study, we sought to define the tibiofemoral relationship more accurately with use of stress radiographs of human knees after anterior cruciate ligament rupture and after anterior cruciate ligament reconstruction. METHODS: A previously described radiographic technique was used to evaluate the position of the tibia relative to the femur with the application of an anteriorly directed tibial force and subsequently with the application of a posteriorly directed tibial force. Tibial position and total tibial translation were calculated from these radiographs. In addition, KT-1000 measurements were obtained. Three groups of patients were studied: Group 1 included twenty-eight patients with an untreated anterior cruciate ligament rupture, Group 2 included nineteen patients who had undergone a clinically successful anterior cruciate ligament reconstruction, and Group 3 included twenty-five control subjects with normal knees. RESULTS: KT-1000 testing showed that the average side-to-side differences in Group 1 (5.8 mm) and Group 2 (2.7 mm) were significantly different from that in Group 3 (0.8 mm) (p < 0.01 and p < 0.05, respectively). Stress radiographs showed that the average total tibial translation in Group 1 (9.8 mm) was significantly different from those in Group 2 (5.6 mm) and Group 3 (4.3 mm) (p < 0.05 and p < 0.001, respectively). Within Group 1, knees with radiographic signs of osteoarthritis were more stable, with an average total tibial excursion of 6.8 mm. The improved stability of the reconstructed knees in Group 2 and the osteoarthritic knees in Group 1 was not entirely the result of decreased anterior tibial translation; it was, in part, due to an irreducible anterior subluxation of the tibia. A posteriorly directed stress in these knees did not reduce the tibia to the anatomic position relative to the femur; the osteoarthritic knees in Group 1 were 9.9 mm short of full reduction and the knees in Group 2 were 3.1 mm short of full reduction (p < 0.01) CONCLUSIONS: Irreducible tibial subluxation can be present in the knee following surgical reconstruction of the anterior cruciate ligament. Osteoarthritic changes following an untreated anterior cruciate ligament rupture are also associated with uncorrectable tibial subluxation along with a decrease in instability. The irreducible tibial subluxation could explain why osteoarthritic changes still may develop in stable, reconstructed knees in spite of the improved stability. Currently used arthrometric measurements, such as KT-1000 scores, do not measure this phenomenon.

Adult↗
PubMed2004

Sideline management of acute knee injuries.

Sideline management of acute knee injuries requires medical personnel to have knowledge of injury patterns, mechanisms, physical findings, and treatment strategies. Fractures and multiple-ligament injured knees need to be rapidly diagnosed and stabilized to allow for timely transfer to a location where further evaluation and definitive treatment can be provided.

Acute Disease↗
PubMed2000

Proximal tibial physis fractures and the use of noninvasive studies in detecting vascular injury: a case report and literature review.

A fracture to the proximal tibia physis is a relatively rare injury, possibly because of the relatively protected position of the physis in the knee. Rarer yet is a displaced, apex-anterior, growth plate fracture. This injury should be regarded as a knee dislocation and evaluated for the potentially catastrophic outcome of a thrombosed popliteal artery. The risk of vasospasm in children from an invasive procedure (e.g., angiogram), however, must be taken into account. This article presents an unusual case of an anteriorly displaced proximal tibia physis fracture in a 14-year-old boy. A noninvasive solution for evaluation of the potential vascular injury is proposed.

Adolescent↗
PubMed2000

Confidence of graduating family practice residents in their management of musculoskeletal conditions.

A study was undertaken to determine the confidence of graduating family practice residents in the management of musculoskeletal conditions and to determine the level of exposure of graduating family practice residents to fracture care. A 2-page questionnaire consisting of 50 items was sent to 680 graduating family practice residents at 100 randomly selected residency training programs throughout the United States. Family practice residents were questioned about their fracture care experience, including the number of fractures diagnosed, the number of fractures reduced, the number of fractures treated to healing, and the number of casts and splints applied. Residents were also asked about their training experience on an orthopedic surgery service. Residents were asked to rate their confidence on a scale of 1 (least confident) to 10 (most confident) in the physical examination, radiographic evaluation, diagnosis, and treatment of a variety of musculoskeletal conditions, including physical examination of the knee, lower back, ankle, wrist, cervical spine, shoulder, hand, and foot; radiographic evaluation of the lumbosacral spine, traumatic cervical spine, hand injuries, adult shoulder trauma, osteomyelitis, and pediatric elbow injuries; diagnosis of carpal tunnel syndrome, herniated lumbar disc, knee instability, rotator cuff tear, and shoulder instability; and treatment of ankle sprain, tennis elbow, olecranon bursitis, distal radius fracture (Colles), bimalleolar ankle fracture, hip avascular necrosis, knee dislocation, and pediatric elbow fracture. These results were compared with graduating family practice residents' confidence in the physical examination, radiographic evaluation, diagnosis, and treatment of a variety of nonmusculoskeletal conditions. Completed questionnaires were returned by 351 graduating family practice residents. The overall fracture care experience of graduating family practice residents was minimal. Seventy-nine percent of graduating residents had reduced 5 or fewer fractures during their entire residency training program. Experience with cast and splint application was also relatively limited. Graduating family practice residents reported an average of 5.1 weeks (range, 0-10 wk) of training experience on an orthopedic surgery service during their residency. Graduating family practice residents were significantly more confident in the physical examination, radiographic evaluation, diagnosis, and treatment of nonmusculoskeletal conditions than in those of musculoskeletal conditions (P = .0001). Family practice residents who had rotated on an orthopedic service for 8 weeks or more during their training reported significantly higher confidence for all 4 skills-physical examination (P = .003), radiographic evaluation (P = .003), diagnosis (P = .007), and treatment (P = .009). In conclusion, family practice residents show relatively low confidence in the management of musculoskeletal conditions and receive minimal exposure to all aspects of fracture care. Confidence can be improved with greater exposure to the musculoskeletal sciences--such as a rotation of 8 weeks or more on an orthopedic surgery service.

Adult↗
PubMed2003

Flexion instability in primary total knee replacement.

Although the results of TKR are highly successful at long-term follow-up, failures occur. One of the more frequent causes of failure is instability. In distinction to instability in the medial-lateral plane, AP instability in flexion has been poorly described until recently. Although acquired ligamentous incompetence can occur, particularly with cruciate retaining prostheses, many cases of flexion instability result from an intraoperative failure to create symmetric balanced flexion and extension spaces. In primary TKR, use of a well-designed posterior stabilized prosthesis and creation of symmetric balanced flexion and extension gaps should minimize the incidence of postoperative flexion instability. If flexion instability occurs, the role of nonoperative treatment is limited. In most cases, revision TKR using the same basic principles is required. When symmetric flexion and extension spaces cannot be produced intraoperatively in complex primary or revision surgery, use of a more constrained articulation, such as a constrained condylar prosthesis or hinged prosthesis, is required.

Arthroplasty, Replacement, Knee↗
PubMed2003

[Graft remodeling following Hertel ACL reconstruction in MR imaging].

MRI and clinical assessment of 21 patients operated on with Hertel method due to knee instability has been presented. Position of the graft in reference to the Blumensaat line has been evaluated in MRI with the use of 3 point scale after mean follow-up of 9-months. Four points scale has been used to grade signal intensity as indicator of graft remodeling. Lysholm scale served for clinical assessment. Mean grade for graft position was 2.3 and for signal intensity 2.7. Better remodeling of the graft correlated positively with its better positioning, but clinical assessment correlated poorly with signal intensity and localization of the graft. Incorrect positioning of the graft hinders its remodeling--ligamentization of the tendon.

Adult↗