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Significant injuries to the musculoskeletal system usually result in a radiographic abnormality. The physician is faced with the problem of recognizing and correctly interpreting these abnormalities. The best way to recognize an abnormality is to thoroughly understand what is normal. Knowledge of normal appearances and relationships will allow identification of even subtle fractures and dislocations.
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Over the years, orthopedic surgery has become more involved in the care of the rheumatoid patient. A more active and aggressive attitude by orthopedic surgeons has thrown new light on the handling of the rheumatoid patient. Currently, the surgical treatment of rheumatoid arthritis is evaluated not only by the outcome of a procedure on a single skeletal part but also by the generalized effects of the disease on the activity of the patient and the function of neighboring joints. Soft-tissue procedures, such as synovectomy and release operations, have been beneficial. Prosthetic surgery yields satisfactory results, and every effort should be made to give the rheumatoid patient as long a period as possible with relief of pain and increased mobility.
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Common injuries to the hand and wrist of athletes have been discussed under the headings of ligament injuries, fractures, tendon injuries, and neurovascular injuries. Although the frequency and mechanisms of certain injuries may be different in the athlete than in the nonathlete, the principles of proper early diagnosis and adequate treatment are the same whether the patient is an athlete or not.
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Pain in the pelvis and lower back appears to be becoming an increasing problem in Norway. The relation between pelvic pain and low back pain is unclear. In the literature a variety of designations, such as pelvic girdle relaxation, pelvic joint instability, posterior pelvic pain, peripartum pelvic pain etc. have been used as identifying labels. The condition(s?) seems to be culturally specific for the Nordic countries in particular. However, pelvic pain is also recognized in England, Holland and Australia, but seemingly unknown in France, Germany, Italy and Spain. The article describes the current knowledge--focusing criteria, etiology, prevalence and nomenclature--and points to the need for systematic epidemiological and clinical investigations.
We have reviewed 36 of 39 consecutive patients with an average age of 68 years who had semiconstrained elbow replacement for distal humeral nonunion at an average follow-up of 50.4 months (24 to 127). Of these, 31 (86%) had satisfactory results, three (8%) had fair, and two (6%) had poor results; 32 patients (88%) had moderate or severe pain before and 91% had no or only mild discomfort after the procedure. Motion had improved from a mean arc of 29 degrees to 103 degrees before operation to 16 degrees to 127 degrees after surgery. All five flail extremities were stable at last assessment. There were seven complications (18%): two patients had deep infection, two had particulate synovitis, two had ulnar neuropathy and one had worn polyethylene bushes. Five of these seven, excluding the two with transient nueropathy, required reoperation (13%). Joint replacement arthroplasty can be a safe and reliable treatment for this difficult clinical condition, seen most commonly in elderly patients. This is a significant advance, since repeated osteosynthesis has been shown to be ineffective in most patients.
Popliteal cysts may occur with diseases of the knee and may cause several complications. We report about a patient with a popliteal cyst, that contained calcified concrements after a femur fracture and a complex knee injury and that we found to be a rare cause of persisting knee pain and effusions. The etiology of the concrements will be discussed, that we think are more likely to be posttraumatic loose joint bodies than traumatically induced chondromatosis.
The present report describes the results of long-term follow-up after arthroscopic replacement of the anterior cruciate ligament with a synthetic ligament made of "Trevira-Hochfest". Over a period of 27 months 88 Trevira ligaments were implanted at the Department for Trauma Surgery of the Krankenhaus der Barmherzigen Brüder in Eisenstadt using the arthroscopic assisted two-drill-hole technique. The overall complication rate found after follow-up for up to seven years was 47.7% (42/88). In 14 patients ligament ruptures occurred within the first 24 months after surgery; a further 8 ruptures were seen in the subsequent years. Including the 12 instable knee joints found at the time of the follow-up, the overall rupture rate seen was 38.6% (34/88). In obvious contrast to reports on comparable synthetic ligaments, the ruptures seen invariably showed smooth rupture surfaces without any fraying. In all of the cases removal of the ruptured ligaments was possible without any problems. It is highly likely that this material-specific characteristic is also responsible for the comparably low incidence of synovitis (18%) with only one of our patients requiring an explantation of the synthetic ligament due to recurrent synovitis. Of the patients with intact Trevira ligaments excellent or good results in the OAK-Score were seen for 76.8% at follow-up after up to seven years. Follow-up stability tests performed in 69 patients showed intact Trevira-ligaments in 57 cases (82.6%). The radiographic findings obtained for the postoperative follow-up for up to seven years failed to show any clinical evidence of the arthrosis-promoting effects of foreign-body synovitis demonstrated in experimental models.
Forty two patients (45 feet) who underwent operative correction of acquired hallux varus were retrospectively evaluated. The causes of hallux varus included complications after hallux valgus surgery (36), trauma (3), rheumatoid arthritis (3), unknown (2), and osteoarthritis (1). The methods of surgical correction were determined by the underlying etiology, the age and activity level of the patient, and the site of primary deformity. Surgical corrections included medial soft tissue release alone (2), medial soft tissue release combined with tendon transfer (17), metatarsal osteotomy with (1) or without (1) additional tendon transfer, arthrodesis (17), and resection arthroplasty (7). The tendon transfers used included a split extensor hallucis longus (6), an extensor hallucis longus transfer in combination with interphalangeal joint arthrodesis (7), and an extensor hallucis brevis (4). All patients were evaluated at a mean of 3.8 years (range, 1-7 years) after surgery. Pain, problems with shoe wear, and metatarsophalangeal joint instability, if present preoperatively, were improved in all treatment groups. An algorithm for the operative management of hallux varus is presented.
Until the 1930s all meniscal lesions were considered to be of traumatic origin. The efforts of Magnus and his pupils led to a more differentiated medicolegal interpretation of wear and tear of the meniscus and classification of at least some types of meniscal lesions as nontraumatic in the sense of accident insurance. This caused controversy, continuing to the present day, as to whether trauma or degeneration is essential for a meniscal tear. This debate can now be closed. Numerous investigations of meniscus pathology have proved that the isolated, essentially traumatic meniscal tear does not exist. Only if the viscoelastic properties of meniscus tissue are changed may indirect force cause a rupture. There is no longer any reason to follow principles for the assessment of meniscus damage differing from those for tendon or intervertebral disc lesions. Only penetrating joint injuries or joint fractures may lead to a direct meniscal lesion (corresponding to penetrating spine trauma or vertebral body fracture with concomitant disc lesion). Separation of the meniscus from its insertion is the analog of discoligamentous spinal trauma. Post-traumatic meniscus degeneration due to joint instability is equivalent to the instability of the motion segment with intervertebral disc degeneration. Isolated meniscal tears and isolated intervertebral disc ruptures cannot be caused by indirect force. The conventional, inconsistently applied criteria to distinguish traumatic and degenerative meniscal lesions are no longer necessary.
Infection after total elbow arthroplasty (TEA) is a devastating complication. Current management options include (1) salvage of the implant with debridement and parenteral antibiotics, (2) resection arthroplasty, and (3) arthrodesis. Most infected TEA patients ultimately require resection arthroplasty. Inadequate bone may preclude both revision TEA and successful resection arthroplasty. It is in these cases that the patient may benefit from allograft reconstruction. Two patients with painful flail elbows secondary to previous resection arthroplasties were treated successfully with cadaver allograft augmented with in situ autograft. Use of the allograft resulted in improvement from failure to excellent in this patient with posttraumatic arthrosis at five years after operation and from failure to good in a rheumatoid patient at two years after operation. Autograft-augmented allografts in the resected failed-TEA patient are a valuable and bone-preserving option. This may be especially useful in patients with significant bone loss or young patients with posttraumatic arthrosis, for whom arthrodesis may be the only other surgical option. The method should not preclude further revision TEA.
In this paper, the changes in the stiffness of eight lumbar spinal segments, as affected by left unilateral partial or total facetectomy, were investigated by means of an electro-mechanical technique. The results showed that with unilateral facetectomy, the stiffness of lumbar spinal segment was 39% less in axial rotation, 14% less in extension, 13% less in lateral bending and 9% less in flexion. This observation suggests that in general clinical practice, close attention must be paid to the patients with facet injury, because in this situation the ability of lumbar spine in resisting torque may be decreased significantly.
Malunion, non-union, as well as painful ligamentous joint instability following fractures to the distal forearm may seriously compromise the function of a hand. Forty-seven surgically treated cases, thirty-nine of which were followed up, are presented in order to point out the problems of such lesions. Retrospective evaluation of the lesion is absolutely mandatory, as it often dates back to childhood. Management should take clinical findings as well as the patient's functional demands on his hands into consideration, but without overestimating therapeutic potentials.
In 1981 through 1989 authors performed 160 complex reconstruction operations for instability of the knee joint according to the basic principles of W. Müller, striving to restore all structures injured. 92 patients with 378 operations were controlled. The assessment of the results was based on the physical examination, the measurement of ligament laxity with the K 1000 arthrometer, the opinion of the patients, the level of their activity and Lysholm's functional point system was used. The stability of the knee could be restored in 73 per cent of the cases. The patients have thought the knees, found more stable with the arthrometer, really more stable. There was however no unambiguous relation between the knee stability and the level of activity of the patients. The most frequent complaint was pain, increased synovial fluid and the hindrance of squatting. The results were better if the patient had no previous operation in an other department and in those who did not need menisectomy, who had less operations, less body weight and better muscular force.