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The management of patients with antero-medial rotatory instability of the knee is described. The therapy of the special patient depends on the age of the patient and the extent of instability. The therapy is also influenced by the degree of degenerative arthritis and differs between well trained and untrained persons.
Anteroposterior X-ray views of both acromio-clavicular (AC-) joints with 10 kg weights in each hand are generally accepted for the diagnosis of Tossy I to III AC-joint separations. An analogue diagnosis can be made by standardized ultrasound examination. Ten individuals without AC-instability (Tossy I), eleven with Tossy II- and eight with Tossy III-instability were examined both radiographically and by B-mode ultrasound. AC-joint width was uniformly calculated by using an index (AC-index = AC-joint width of uninjured side/AC-joint width of injured side). The sonographically measured mean AC-index for Tossy I-stability was 1.0; sonographically 0.49 and radiographically measured 0.5 for Tossy II-injury; and sonographically 0.21 and radiographically measured 0.2 for Tossy III-instability. Statistical analysis resulted in significant differences for all mean AC-indices of the three groups (p < 0.0001). We conclude that ultrasound examination of AC-joint instability is as reliable as radiographic measurement. Standard X-rays of the shoulder remain mandatory to exclude fractures only. The decision for operative stabilisation of the AC-joint can be based on the side-effect free and cost-effective ultrasound examination of the grade of AC-joint instability (AC-index < 0.3 equivalent Tossy III).
The importance of instability in the determination of painful syndromes of the shoulder is examined, with particular reference to young people who engage in sport. The physiopathology and clinical features are described, and the importance of diagnostic tests is emphasized. These often disclose the underlying pathological anatomy. Surgical treatment, which is indicated whenever the lesion is well documented, follows the methods used in treating recurrent dislocation. The validity of the method of Latarjet and Bristow is emphasized.
Anteroposterior X-ray views of both acromioclavicular (AC) joints with 10-kg weights held in each hand are the generally accepted procedure for diagnosis of Tossy I-III grades of AC joint separation. An analogous diagnosis can be made by standardized ultrasound examination. Ten individuals with Tossy-I, 11 with Tossy-II and 8 with Tossy-III instability were examined both radiographically and by B-mode ultrasound. The degree of AC joint separation was uniformly determined on the basis of a calculated index (AC Index = AC joint width of uninjured side/AC joint width of injured side). The mean AC Index for Tossy-I instability determined by ultrasound was 1.0; mean indices of 0.49 and 0.5 were determined for Tossy-II injury by ultrasound and X-ray, respectively, and of 0.21 and 0.2, respectively, for Tossy-III instability. Statistical analysis showed significant differences between the mean AC indices of all three groups (P < 0.0001). We conclude that the reliability of ultrasound examination of AC joint instability is equal to that of radiographic measurement. Standard X-rays of the shoulder remain mandatory only to exclude fracture. The indication for operative stabilization of the AC joint can be established on the basis of the grade of AC joint instability measured by the side-effect-free and cost-effective method of ultrasound examination (AC Index < 0.3 equivalent to Tossy-III instability).
During 1979 to 1986 72 patients have been treated surgically because of "anterolateral rotation instability" of the knee joint. The follow-up of 51 patients is based on the AOK-method. The surgical technique (modified gracilis and iliotibialis replacement) is described. 82.4% ended up in a good to very good result, in patients' view even 88.2%. The cases with bad and medium results are discussed, as well as those who underwent further treatment elsewhere.
An analytical study was made of 30 knees by dissection, 200 by conventional radiology, 120 by CT scans, and of 2,400 pathological knees by conventional radiology, and 900 by CT. The radiological and scanning methods most used for a study of the femoropatellar articulation are described and the normal values of each feature determined by a computer study. The femoral trochlea and its shape are very important for the stability of the patella. The normal and pathological types of trochlea are described. This study established a number of anatomical factors which influence patellar stability, and form a basis for proposing the correction of anatomical anomalies in the treatment of instability of the joint.
Overall 119 treatment and prophylactic operations were performed on those patients in early phases of rheumatoid arthritis who derived no benefit from a combined conservative treatment. With preliminary medial instability of the joint in 19 patients the surgical intervention involved some elements making for reinforcement of the capsular ligamentous apparatus. Good results of the above operations occurred in 78% of cases. Relapses of synovitis were encountered in eight percent of cases, which fact is related to the generalized advancing disease. Satisfactory results were obtained in those patients (14%) who were free from the origination of synovitis, which fact can be explained by lack of an efficient system of complex medical rehabilitation in the outpatient stage. A scheme is suggested of medical rehabilitation after treatment and prophylactic interventions for patients with early stages of rheumatoid lesions of the knee joint, that permits improving results of treatment in the above category of patients.
Treatment of patients with an established disabling compartment arthrosis after total meniscectomy is an important clinical problem. Meniscal transplantation may be an alternative method of treatment. Between 1989 and 1992, 25 cryopreserved nontissue antigen matched meniscal transplantations were performed. In three patients with a medial meniscus, the transplantation failed because of partial loosening of the meniscus. The donor meniscus was removed in one case after 12 months and in the other two cases after 20 and 24 months. In two cases, there was a varus malalignment of the knee. In the third case, the knee was unstable because of an insufficient anterior and posterior cruciate ligament. The retrieved menisci were stained with enzyme and immunohistochemical reactions. Focal areas of degeneration were noted, with vital cells around the microvascular supply and at the synovial side. The growth potential of vital parts of the grafts, as shown by proliferation markers, seemed to be virtually nil. The success of meniscal transplantation seems to depend on factors responsible for vascularization. Malalignment and instability of the joint, causing abnormal pressure on the graft, may be responsible for vascular damage leading to degeneration and loosening of the graft.
Lateral instability in the subtalar joint was documented by a method of stress tomography in three patients. The subtalar inversion angle averaged 38 degrees +/- S.D. 6 degrees in asymptomatic feet and 57 degrees +/- S.D. 5 degrees in those with unstable subtalar joints . Review of the literature suggests that as many as 10 per cent of patients having the Watson-Jones procedure for abnormal talar tilt also have instability in the subtalar joint. It is felt that the subtalar joint should be evaluated in patients seen with the clinical symptom of lateral instability.
Chronic painful post-traumatic instability of the radial collateral ligament complex of the metacarpophalangeal joint of a finger was treated by tendon graft reconstruction in 24 patients. Seventeen patients (20 joints) were available for a retrospective study at a mean follow-up time of 105 months. Eighty percent of the joints showed excellent or good results, with relief of pain, return of adequate stability, a near normal range of motion and absence of degenerative changes.
Post-traumatic instability of the metacarpophalangeal joint of the thumb has been treated surgically in sixty-six patients. The results in eighty per cent were excellent or good.
Human cadaver thumbs were tested to evaluate stability of the radial side of the MP joint. The contributions of the dorsal capsule, radial collateral ligament, accessory collateral ligament, and volar plate were examined with the joint in 0 degrees and 30 degrees of flexion. At 0 degrees flexion, the average joint angulation increased 4 degrees following isolated radial collateral ligament transection and 6 degrees following isolated accessory collateral ligament transection. Release of both the accessory and radial collateral ligaments produced marked instability with joint angulation of at least 46 degrees. The accessory collateral ligament helped to stabilize the extended MP joint. There were no significant contributions to stability from the dorsal capsule and volar plate when the collateral ligaments were intact. In the laboratory setting, radial-side instability of the MP joint of the thumb requires transection of both the proper and accessory radial collateral ligament.
PURPOSE: This study presents an autograft technique for the surgical management of chronic posttraumatic instability of the thumb metacarpophalangeal (MCP) joint by using a bone-retinaculum-bone graft from the second compartment of the extensor retinaculum. METHODS: The bone-retinaculum-bone graft was harvested from the second compartment. The graft ends were fixed into the host site with screws. Fourteen patients (12 ulnar, 2 radial collateral ligament tears) had the procedure. All patients were reviewed by an independent observer using objective and subjective criteria, the mean follow-up time was 20 months. RESULTS: Results were satisfactory overall (8 excellent, 4 good, 1 fair, 1 poor that subsequently was fused). All patients returned to their former jobs. All but one had a clinically stable first MCP joint; grasp was 87%, pinch was 80%, MCP joint range of motion (ROM) was 91%, and interphalangeal joint ROM was 98% of the unoperated side. CONCLUSIONS: Early results are encouraging. This procedure preserves ROM of the MCP and interphalangeal joints of the thumb, improves strength, and gives the stability required for proper thumb function.
A series of 16 cases of chronic instability of the metacarpo-phalangeal joint of the thumb is presented. The authors begin by summarising the two main surgical procedures used in such cases: ligamentous reconstruction and arthrodesis. In our series, a ligamentous reconstruction with Smith's procedure was performed in 13 patients, a primary arthrodesis in 2 patients and a secondary suture in one patient. The results are analysed in 15 patients (7 women, 8 men) with a minimum followup time of two years. Failure was noted in 4 cases treated by ligamentous reconstruction (3 men and 1 woman). An arthrodesis was subsequently performed in all these patients. There were therefore a total of 6 arthrodesis and 8 ligamentous reconstruction to review. Ligamentous reconstruction gave better functional results than arthrodesis in particular as regards mobility, opposition of the thumb and strength of pinch grip (decreased by 50% with arthrodesis). In manual workers the use of ligamentous reconstruction in these cases was shown in our series to give inconstant results.
The anterior drawer test is commonly used in the diagnosis of ankle joint mechanical instability. However, the effect of axial load on the anterior drawer test has not been examined in vivo. The purpose of the study was to assess the effect of axial load on passive anterior instability, and on the diagnostic measurement of the anterior drawer instability of the ankle joint complex. A total of 21 subjects with various degrees of ankle sprains were tested on a device that could continuously record applied anterior force and the resultant displacement of the rear-foot. Anterior drawer flexibility of the ankle joint complex in a neutral dorsi/plantar flexion position was quantified on both feet for all subjects without and with an axial load (385 N). Flexibility of the ankle joint complex in anterior drawer was defined as the slope of a linear load-displacement curve (which fitted test data with high correlation coefficients (r>0.991)). With axial load, anterior drawer flexibility was significantly reduced by 28.8% compared to that without axial load. The difference in anterior drawer flexibility between injured and intact ankles significantly decreased with axial load. An axial load increased the stability of ankle joint complex. However, axial load reduced the sensitivity of anterior drawer test to mechanical instability of the ankle joint complex.
Repair of chronic ankle instability is recommended by a step-to-step approach. Anatomic repair with ligamentoplasty or periosteal flap will result in complete range of motion of the foot, but with less stability (7.1 degrees talar tilt). The more unphysiologic tenodesis procedure should be done in long-standing cases and gross instability, with the risk of loss of motion (10 degrees supination in one third of the cases), but with the advantage of best mechanical stability (3.5 degrees talar tilt).
Between 1984 and 1989, 108 patients who had chronic lateral instability of the ankle were treated with a modified Evans tenodesis, in which the anterior half of the peroneus brevis tendon was used for reconstruction. Follow up was possible by questionnaire in 75 patients and by clinical examination in 46, after 29-122 months (mean 68 months). Subjectively excellent or good results were achieved in 62 patients (82.6%) while 9 (12%) had fair results and 4 (5.4%) a poor outcome. Pain during physical activity was reported by 27 patients (35%), loss of inversion by 34 (45%) and slight instability by 31 (41%). The X-ray films at follow-up revealed more signs of arthrosis than had been present preoperatively. The stress tests showed an anterior drawer of 7.8 mm preoperatively and 7.0 mm postoperatively (p = 0.03); talar tilt was improved from 7.7 degrees to 4.5 degrees (p < or = 0.01). The outcome reported by the patients and the objective results of the clinical and radiological examinations were at odds. Pain, instability and osteophyte formation after the operation were so frequent because the talus was not fixed when the Evans reconstruction was implemented. Therefore, we suggest that this method should not be used in patients with a high activity level.
A follow-up study is presented of 26 ankle joints with recurrent lateral instability, treated with surgical repair by the Evans method. The median follow-up period was 3.1 (range 1.1-6.9) years. Normal stability was achieved in 73 per cent of the ankles, and another 12 per cent were improved. Similar results are obtained with other methods of surgical repair. Preoperatively 82 per cent of the joints had a positive anterior drawer symptom. This was only found in 12 per cent postoperatively, and these ankles were all classified as having poor results, indicating the importance of reconstruction of the anterior talofibular ligament.