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PubMedDate not supplied

[Tactics of surgical treatment for an inflammatory process of C0-C(I)-C(II) segments in the craniovertebral joint instability].

Pathological processes of C0-C(I)-C(II) segments, such as the clivus, atlas arch, dens, and body of the C, vertebra pose major problems for diagnosis and treatment. On removal of a sizable pathological focus, there may be instability of the craniovertebral segment, secondary displacement, and spinal compression syndrome. Therefore these patients frequently need stabilization of the craniovertebral transition. Patients with initial instability of the craniovertebral junction and subluxation of C(I)-C(II) segments are an intricate problem. The authors describe a rare case of an inflammatory process of C0-C(I)-C(II) segments with craniovertebtal junction instability. A differential diagnosis was made between chordoma, osteoblastoma, and an inflammatory focus at the above site. The following tactics was undertaken: the first stage was occipitospondylosynthesis with "Vertex" system with osteoplasty under Halo-traction; the second stage included transoral removal of a pathological removal of the dens and body of the C(II) vertebra, left lateral mass of the CI vertebra, and lower clivus. After removal of the pathological focus, there were portions of the abnormally changed bone with rarefaction without tumor tissue. Histologic studies revealed the signs of a chronic inflammatory process. A five-month follow-up showed that neurological symptoms and craniovertebral junction instability regressed. The control computed tomography made 5 months after surgery demonstrated the radical elimination of the pathology and the absence of C, vertebral subluxation. Thus, there is evidence for the tactics of successive operations (a stabilizing operation--posterior occipitospondylosynthesis (desirably under Halo-traction), followed by removal of a pathological focus via transoral access) in pathological processes of the craniovertebral C0-C(I)-C(II) in cases of initial craniovertebral junction instability.

Atlanto-Occipital Joint↗
PubMed1991

Advances in the understanding of anterior instability of the shoulder.

Anterior instability involves a spectrum of disease ranging from the obvious acute first-time dislocation to the athlete presenting with shoulder pain and no history suggestive of instability. It is important to recognize the pathophysiology and how it relates to this spectrum of disease. The arthroscope has helped to identify the underlying pathology in both acute and chronic situations. Diagnostically, a history of a painful shoulder, especially in the athlete, should suggest anterior instability. Tests of translation, apprehension, and the use of local anesthetic can be useful. Arthroscopy is used in situations in which the diagnosis is unclear. The management of anterior instability should emphasize strengthening of the rotator cuff and scapular stabilizers. Surgical repair requires correction of the underlying pathology with minimization of damage to other structures. Arthroscopic management of anterior instability includes repair, debridement of intra-articular lesions, and the possibility of acute correction of the pathoanatomic lesions.

Humans↗
PubMed1991

Controversy in anterior shoulder instability.

The main areas of controversy in anterior shoulder instability are acute dislocation, recurrent instability, pain and instability in the "throwing athlete", and the role of arthroscopy. Treatment of the acute dislocation involves rest initially, followed by aggressive rehabilitation with protection of the shoulder until strength and motion have returned and pain and apprehension have resolved. Patients with recurrent instability may be seen with a variety of clinical scenarios. The surgical indications, pathology, and two methods of soft-tissue reconstruction are described along with an approach to postoperative rehabilitation. Return to sporting activity may be feasible by three months. The current thinking on the painful shoulder in the "throwing athlete" is outlined. Management must be based on an accurate diagnosis. Strengthening of the rotator cuff and scapular stabilizers is recommended with surgery to correct the pathology in those who fail this program. Arthroscopy is a valid tool in the diagnosis of anterior shoulder instability. The clinical significance of some intraarticular findings has not yet been clarified. Therapeutic use should be undertaken only in experienced hands, appreciating that failure of arthroscopic repair is higher than comparable open surgical techniques. The open approach to anterior stabilization is preferred.

Arthroscopy↗
PubMed1991

[Lateral instability of the ankle joint (2). Active training programs can prevent surgery].

One hundred consecutive patients with chronic lateral functional instability of the ankle were treated non-operatively with physiotherapy (active range-of-motion training, strengthening exercises and co-ordination training with a tilt-board). All patients were evaluated functionally with a special rating scale, and radiologically with standardised stress radiographs measuring anterior talar translation (ATT) and talar tilt (TT). Excellent or good functional results were obtained in 49 of the patients, fair or poor in the remainder. The outcome was better in those with painful functional instability or mild mechanical instability, while those with more pronounced mechanical instability required further treatment (i e, reconstructive surgery). Of 10 patients with generalised joint laxity, only fair or poor results were obtained in seven, all of whom had mechanical instability.

Adult↗
PubMedDate not supplied

[Which knee ligaments must be reconstructed in anterior and posterior valgus and varus instability? An experimental study].

This study aims to localize the ligamentous lesions in distinct knee joint instabilities. For that reason 41 human cadaver knee joint specimens were tested in a three-dimensional determined apparatus. Ligaments were successively dissected and forces and torques were introduced. Both cruciates are the dominant structures in preventing straight anterior und posterior movement of the tibia. As a supporting element the postero-medial capsule prevents anterior dislocation in ACL-deficient knees. Therefore extraarticular procedures in cruciate instabilities will not be successful. In contrast varus- and valgus instabilities resulted after transsection of a couple of ligaments. Valgus stability decreased after cutting the medial collateral, posterior oblique and both cruciate ligaments. The most important element in preventing straight varus instability was the lateral collateral followed by the posterior cruciate ligament, while the popliteus tendon had only little influence. Therefore in medial and lateral instabilities all supporting structures should be exposed and reconstructed.

Anterior Cruciate Ligament↗
PubMed1990

[Conventional diagnosis of carpal luxation and instability].

The recognition of ligament disruption in carpal dislocation and the early diagnosis of carpal instability have had implications for the therapy since the evolution of differentiated surgical treatment concepts including ligament reconstruction. Plain radiography and the carpal instability series are helpful in the detection of ligament disruption. The radiological analysis is based on the configuration and arrangement of the carpals, the setting of their axes, and the detection of intercarpal gaps. Mechanisms and characteristic radiological findings in the different types of carpal dislocation and instability (scapholunate dissociation, palmar or dorsal intercalated segment instability) are demonstrated in relation to physiological appearance, and the value of conventional films in the diagnosis of carpal dislocation and instability is discussed.

Carpal Bones↗
PubMed1989

[Treatment of instability of the knee joint].

The authors present a study of problems of the surgical treatment of acute and chronic instabilities of the knee joint. In cases of recent injuries 32 operations of restoration of the cruciate ligaments and the bursal and ligamentous apparatus were made: in most cases the long-term results were good. The authors believe that timely and adequate treatment of the patients during the acute stage of the disease will allow to bring the problem of the treatment of chronic instability of the knee joint in most patients closer to its practical solution. In primarily anterior and posterior chronic instability associated with a light degree of lateral instability an operation after Augustino is advised, particularly as modified by the authors, as an independent operation or as one of the elements in complex reconstructive operations in the multiplane forms of instability of the knee joint. A detailed description of the surgical technique is given.

Adult↗
PubMed1989

[Comparative study of a series of normal knees and a series of knees with patellar instability].

In studying the long-term follow-up of 39 cases of patellofemoral instability operated in our department for recurrent dislocation, we also analyzed their morphological appearance on X-ray. We compared the data given by Maldague and Malghem, Dejour and Walch for the pathological conditions of our cases with the same number of normal knees. This comparative analysis showed that measuring the bulging of the upper part of the trochlea and the depth of its groove on a lateral view is a reliable method to evaluate patellar instability. The classical axial view gives less useful information to quantify the instability. However, this axial view shows a particular aspect in the cases of severe instability: the fulcrum of the trochlea is displaced inwards while the inner trochlear facet is smaller or even absent. This precise radiological examination and the complete clinical examination with an analysis of the "morphotype" (Lerat) are necessary in the screening, diagnosis and treatment of severe patellofemoral instability.

Follow-Up Studies↗
PubMed1987

Evaluation of knee instability in acute ligamentous injuries.

The stability on clinical examination (CE) and examination under anaesthesia (EUA) was evaluated in 350 consecutive acute knee injuries. Valgus instability in knees with a medial collateral tear was observed on CE in 62 and on EUA in 67 cases (p less than 0.05). The anterior drawer sign was positive in 55 patients on CE and in 110 patients on EUA (p less than 0.0001), the corresponding figures for the Lachman test were 66 and 126 respectively (p less than 0.0001). The pivot shift-test was positive in 13 cases on CE and in 87 under anaesthesia (p less than 0.0001). Fresh total tears of the anterior cruciate ligament (confirmed at arthrotomy, n = 79) were detected by the Lachman test in 48 per cent on CE and in 96 per cent on EUA. Of the nine fresh, total tears of the posterior cruciate ligament three were disclosed by the posterior drawer test on CE and all nine on EUA. Anteromedial rotatory instability was observed on CE in 10 patients and on EUA in 47 (p less than 0.0001). In these patients 41 medial collateral tears, 23 posteromedial capsular tears, 21 medial meniscus and 40 anterior cruciate lesions were found. On CE only one anterolateral rotatory instability was found, whereas EUA disclosed 9 cases. Posteromedial rotatory instability was not confirmed on CE, though on EUA four cases were found. CE and EUA detected 2 and 3 posterolateral instabilities respectively. In conclusion, the use of EUA with an adequate mode of stability evaluation in acute knee injuries is strongly advocated. Clinical examination is considered highly unreliable with many false negative findings.

Acute Disease↗
PubMed1986

[Diagnosis and therapy of acute and chronic ligament instability of the lower ankle joint].

At the Casualty Clinic of the University Hospital in Hannover, from 1981 to 1985, a total of 35 patients were treated operatively for chronic instability of the transverse tarsal joint: combined instability of the ankle and transverse tarsal joints (n = 15), isolated instability of the subtalar joint (n = 17), and isolated instability of the pretalar joint (n = 3). A simple technique of radiological positioning permits easy and certain diagnosis of isolated anterolateral rotary instability of the subtalar joint. Modified Elmslie tendosis (n = 32), used as an indirect replacement for the interosseus talocalcaneal ligament, had good and very good results in 25 of 27 cases followed up after 3 years.

Ankle Injuries↗
PubMed1985

Involuntary inferior and multidirectional instability of the shoulder: etiology, recognition, and treatment.

Multidirectional and inferior instability of the shoulder is not rare. Etiological factors include various combinations of (a) repetitive injuries, (b) inherent joint laxity, and (c) one or more major injuries. It is seen in athletic and active patients without generalized joint laxity and as well in sedentary patients with hypermobile joints. Standard operations for unidirectional anterior or posterior dislocations fail to correct multidirectional instability because they do not correct inferior instability and they may displace the head in fixed subluxation to the opposite side leading to severe arthritis ("arthritis of dislocations"). Proper detection depends on suspecting its possibility in all types of patients and in a wide age range as well. Helpful signs include the sulcus sign, positive apprehension test in multiple directions, stress roentgenograms and fluoroscopy, and evaluations under anesthesia. Arthroscopy may be helpful in doubtful cases, but the findings require clinical interpretation. Selection of patients with multidirectional instability for surgery is extremely difficult because it requires not only great care in determining all directions of instability and planning the repair but also determining the motivation of the patient and excluding the possibility of some other condition being present that is causing pain rather than the joint laxity. The results of inferior capsular shift have continued to withstand the test of time and, though it is more difficult than standard procedures, is considered a very helpful procedure in the treatment of these difficult lesions. The principle is to reduce capsular laxity on all three sides by shortening and reinforcing and to reduce the joint volume.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

The diagnosis and treatment of instability of the subtalar joint.

We have developed a method of measuring anterior displacement of the calcaneus on the talus in instability of the subtalar joint and have used the technique to demonstrate anterior instability in 50 patients (72 feet) showing a positive drawer sign. The angle of the posterior facet of the talus was also measured to assess the bony configuration. Our patients with subtalar joint instability could be divided into three categories. The first group had a history of trauma leading to ankle instability (26 cases), the second showed generalised joint laxity (10 cases) and the third were young females with a history of chronic stress on the foot and a poor bony block (14 cases). Satisfactory results were obtained by treating the instability with a brace or by reconstruction of the interosseous talocalcaneal ligament.

Adolescent↗
PubMed1993

[Treatment of posterior instability of the shoulder joint using an acromial stop with a pediculated deltoid flap].

Our purpose has been to describe an original surgical technique without describing all the problems concerning the posterior instability. The original technique has a double effect: active with the muscular flap and passively mechanic, if necessary, by the bone graft. Five patients have been treated with this technique with a follow-up of one year and a half. 4 females and 1 male with an average age of 32 years 1/2. 2 were recurrent posterior instability, one unintentional and 2 intentional subluxations. 2 were epileptics. In all cases, the disparition of the instability was obtained. Full range of movement and sport were resumed at the former level. On X-rays, the humeral head was centered. By its double mechanism, active with the muscular flap and possibly passive with the bone graft, this technic is reliable to treat the majority of posterior instability. It combines the way of action searched in physiotherapy and capsulomyoplasties to center the humeral head and this one by the bone graft in case of posterior glenoid fracture or dysplasia. It doesn't have the insufficiencies of physiotherapy or capsulomyoplasties in posterior traumatic instabilities, nor from the classical bone graft over the glenoid posterior wall, cause of osteoarthritis and pain.

Acromion↗
PubMed1994

The aging spine: clinical instability.

Clinical instability of the spine is an intensely controversial subject, and its diagnosis, especially in the aging, is difficult. Yet success in its management rests on accurate diagnosis. Because both clinical presentation and radiographic manifestations are nonspecific, the diagnosis of clinical instability lies in understanding the biomechanics involved, in recognizing the relevant radiographic manifestations, and, most importantly, in correlating those observations with the patient's clinical history and physical examination. Stabilization is the treatment of choice for clinical instability. Strengthening of the dynamic stabilizers, especially early in the course of the disease, may prevent or alleviate the incapacitating symptoms of instability, and further research into this area should be undertaken. Static stabilization by bracing has not proved effective, and spinal fusion carries a high risk of complication. Fusion should be reserved for patients whose diagnosis is clear and whose symptoms are recalcitrant to conservative management. Further understanding of clinical spinal instability in the aging will require more precise definition of terms and better standardization of criteria for its diagnosis, management, and research.

Adolescent↗
PubMed1993

Carpal instability in rheumatoid arthritis.

The authors examined prospectively the prevalence of and relations among patterns of carpal instability in 52 patients with proven rheumatoid arthritis. Posteroanterior, lateral and oblique radiographs of both wrists were obtained. Nineteen patients exhibited one or more patterns of instability. The most common isolated pattern was volar intercalated segmental instability, apparent in six patients. Five patients showed more than one pattern, most commonly a combination of ulnar translocation and volar carpal subluxation. Patients with active erosions or changes in the distal radioulnar joint were more likely to exhibit instability than those without such findings. Carpal instability is a frequent mechanical complication of rheumatoid arthritis. The radiologist should be aware of this possibility, so that a diagnosis can be made promptly and appropriate clinical management begun.

Arthritis, Rheumatoid↗
PubMed1995

Glenohumeral instability.

Glenohumeral instability can be defined as pain associated with loss of shoulder function due to excessive translation of the humeral head on the glenoid fossa. It can be classified according to many factors, such as direction, degree, mechanism, and frequency. A thorough understanding of the anatomy and biomechanics of the shoulder joint as they relate to instability is helpful in understanding the pathophysiology of this condition. All components of the instability must be correctly diagnosed so that appropriate treatment can be selected. Clinical examination is most important in making the correct diagnosis, but plain radiographs, arthrography, computed tomography, magnetic resonance imaging, examination under anesthesia, and arthroscopy can be helpful in difficult and challenging cases. Conservative treatment with a rehabilitation program can be successful in a large percentage of cases and should be the initial approach for most patients. Operative treatment is based on the direction and type of instability and is recommended only after an adequate trial of conservative therapy has failed to improve recurrent instability.

Arthroscopy↗
PubMed1995

[Recurrent anterior and multidirectional instability of the shoulder].

PURPOSE OF THE STUDY: Surgical treatment for recurrent anterior instability associated to multidirectional shoulder hyperlaxity: results analysis. MATERIAL: Twenty five patients operated for recurrent anterior dislocation or subluxation with multidirectional hyperlaxity. Age at operation was low (22 years old), there were more females than males, instability was bilateral in 52 per cent cases. METHOD: Five patients underwent a capsular shift followed by a four weeks post operative immobilization. Twenty patients underwent a bone block procedure with the coracoid process associated with a modified capsular shift. Inferior half of the subscapularis muscle was left intact under the coraco-biceps tendon. RESULTS: The results were fair with only 52 per cent excellent or good results. Ten patients (40 per cent) presented a recurrence either a dislocation or a subluxation. Hyperlaxity recurred in all but three patients. The procedure didn't influence the results which were related to the antecedent: the patients with a previous history of voluntary recurrent posterior subluxations achieved 33 per cent fair or poor results. Patients with previous history of recurrent anterior subluxation achieved 100 per cent poor results, whereas the patients without antecedent achieved 85 per cent good to excellent results. DISCUSSION: Establishing a difference between laxity and instability helps to analyse the patients with an unstable shoulder rather than considering traumatic or atraumatic onset of the instability. Identification of the hyperlaxity and of the antecedents must influence the therapeutic discussion. CONCLUSION: We recommend to use the term multidirectional hyperlaxity rather than multidirectional instability to characterize these patients.

Adolescent↗
PubMed1996

[Arthroscopic aspects and chronologic outcome of lesions of the labro-ligament complex in post-traumatic antero-inferior instability of the shoulder. A prospective study of 91 cases].

PURPOSE OF THE STUDY: The authors present a prospective and mono-operator study of 91 gleno-humeral arthroscopies for post-traumatic antero-inferior instability of the shoulder. The aim of the study was to obtain a dynamic understanding of the relationship between the anatomic lesions to allow the integration of all the described lesions into literature and to produce a natural history of lesions in antero-inferior shoulder instability. MATERIALS: 91 endoscopies for post-traumatic instability of the shoulder were performed by the same surgeon. Revision chart comprised 67 purely descriptive items. For the purpose of the study, the patients were divided into 4 groups of dislocation (first dislocation: 9 cases, 1 to 2 recurrences: 12 cases; 3 to 5 recurrences: 23 cases; more than 5 recurrences: 32 cases) and 1 group of subluxation (15 cases). METHOD: The statistical evaluation of each individual data item gathered value allowed the selection of the most significant lesions and to regroup them into "lesions families", relations to the same physiopathological mechanism (traumatic or degenerative). The correlation between each lesion in terms of evolution, age and number of recurrences was studied. RESULTS: The first and most constant lesion is the periosteal avulsion of the antero-inferior labrum ("single lesion": healing potential of +/- 30 per cent, in ectopic position in +/- 90 per cent). With recurrences, the avulsion of the gleno-humeral ligament adds this "single lesion" ("double lesion". Healing potential of +/- 50 per cent, in ectopic position in +/- 90 per cent). Continuing the recurrence, we also noted a degenerative and plastic deformation under the level of the glenoid rim ("triple lesion": infra-glenoid degenerescence) then over the glenoid rim ("quadruple lesion": supra glenoid degenerescence). The age factor and duration of evolution were not negligible and one must associate the "labro-ligament complex" studies with the avulsion lesions of the long head of the biceps (SLAP lesions) in which the frequency varies from 15 per cent to 30 per cent and which was consistently present in patients above 35 years of age. DISCUSSION: The authors believe that recurrences give rise to a progressive worsening of the lesions by the sum of the separate lesions. They propose a physiopathological classification in 4 stages where each lesions has its own healing potential, which explains the apparent large variation in endoscopic aspects of antero-inferior shoulder instability. CONCLUSION: This classification should permit a precise therapeutic strategy in post-traumatic anterior instability, according to the most recent techniques of endoscopic reattachment of the labro-ligament complex.

Adolescent↗