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Benign synovioma is a rare cause of symptomatic instability of joints of the lower limb. We report two cases presenting in this way. Arthrotomy is indicated to ensure adequate excision of these lesions if recurrence is to be avoided.
The relation between anterior instability in the ankle joint and rupture of the anterior talofibular ligament was investigated in patients with acute ankle sprains. Various techniques were used to provoke anterior displacement of the talus. The actual condition of the anterior talofibular ligament was assessed at operation. The appropriate radiographic method was defined, and its valve in diagnosing an acute rupture of the anterior talofibular ligament was assessed.
In the years 1979-1988 65 patients (62 men and 3 women) with rotary anterior-medial instability of the knee were treated surgically. The average age was 34 years. The cause of injuries (65%) were accidents during work in mines of pit-coal. 52 patients were treated surgically in the period of 7 days after the accident. The remaining 13 ones were operated on after the period of 6 weeks. In the group of patients operated on immediately the most frequently applied procedure was the suture according to O'Donoughe of the injured ligaments and shift of the goose foot according to Slocum and Larson. But when the anterior crucial ligament was broken in the shape of a "brush", its reconstruction was formally made according to Jones. For patients with chronic instability extra-articular plastic operations were performed i.e. shift of the semi-tendinous muscle and shift of the goose foot, as well as intra-articular--in case of injury of the anterior crucial ligament. The period of observation was from 4 to 12 years. Better results were obtained in patients operated on immediately: good result--62%, satisfactory--32% and bad--6%. For all patients with chronic instability the obtained results were only satisfactory.
The knees of 210 institutionalized patients with Down syndrome were evaluated to determine the prevalence of patellofemoral instability and to assess the value of orthotic and surgical treatment. The cases of 151 non-institutionalized patients with Down syndrome were also reviewed. The patella was dislocatable or dislocated in thirty-five knees (8.3 per cent) in the institutionalized group and in twelve knees (4.0 per cent) in the non-institutionalized group. This interfered with walking in some patients, but only three of the patients were unable to walk because of patellofemoral instability. None of the institutionalized patients used any form of orthosis, and only three non-institutionalized patients used an orthosis. Eight knees in five patients had been operated on, and they had an average length of follow-up of 16.8 years. Four of these knees had a satisfactory result. Instability of the patellofemoral joint may occur in patients with Down syndrome but is rarely disabling. Almost all patients with patellofemoral instability adapted to the problem and were able to walk.
Thirty-two patients with clinical suspicion of shoulder instability were the subject of this assessment of MRI (1.5 T G. E. Signa) and its comparison with CT-arthrography (GE8800 and GE9800) of the shoulder. Twenty-seven patients had a final diagnosis established by arthroscopy and five by arthrotomy. The imaging examinations were interpreted independently by three radiologists blinded against history, surgical diagnosis and results of the compared test. The statistical analysis included ROC-curves, sensitivity, specificity and accuracy as well as predictive values. The significance of the comparative results was assessed by the McNemar Sign test. MRI showed significantly better diagnostic results in the evaluation of labral structures (sensitivity 85%, specificity 90%, accuracy 88%) and humeral head impression fractures (75, 82, 78 %). None of the tests were of sufficient diagnostic value to identify capsular abnormalities. CT and MRI results regarding the biceps tendon and loose bodies were similar, however, statistically not significant. MRI proved to be of high diagnostic value in the assessment of the unstable shoulder and compared favorably with CT-A.
PURPOSE: The purpose of this study was to evaluate joint position sense (JPS) in patients with posttraumatic glenohumeral instability. MATERIALS AND METHODS: In 28 patients with posttraumatic instability and in a matched control group of 30 subjects proprioception capability was evaluated. For documentation of proprioception an angle reproduction test (ART) was performed with which joint positions sense (JPS) was measured for abduction, flexion, and rotation in three angles each. RESULTS: In both groups there was a significant better JPS with visual control than without. In contrast to the control group the patients were not able to increase angle reproduction capability without visual control when comparing positions below shoulder level with positions at or above shoulder level. When comparing the patients to the controls there were differences in most of the ARTs with worse results in the patient group. These differences were significant in 150 degrees flexion with and without visual control, in 150 degrees abduction without and in 100 degrees abduction with visual control. For rotation there were trends for almost all joint positions, however, the differences were significant only in the -45 position. When comparing the noninjured contralateral shoulder of the patients with the control group, there still were differences. Again these were not in all joint positions significant, but significant worse JPS could be demonstrated in 150 degrees abduction without visual control, 50 degrees flexion without visual control, -45 degrees rotation without and 0 degrees rotation with visual control. CONCLUSIONS: A proprioceptive deficit can be documented in patients with posttraumatic glenohumeral instability. This may be one reason for permanent instability. The contralateral joint also shows reduction in joint position sense. For consecutive treatment as well as for rehabilitation both shoulder joint should be addressed.
In a prospective study we evaluated diagnostic ultrasound investigation for shoulder instabilities. We measured the passive aptranslation In 150 healthy persons in relation to the dorsal glenoid as well as the inferior subluxation in relation to the acromion. After establishing normative datas we measured 23 patient with unidirectional instabilities and 34 with multidirectional instabilities. The humeral head position of a normal joint is 8 to 10 mm dorsally to the glenoid. In the control group the anterior translation of the dominant shoulder is significantly higher as in the nondominant shoulder (student-t-test; p less than 0.0045). Patients with anterior instabilities showed a significant increase of anterior translation in the injured shoulder (student-t-test; p less than 0.0001). In comparison with the control group there is a significant increase of downward subluxation in patients with multidirectional instabilities (chi 2 alpha less than 0.05). In habitual or voluntary dislocations the relation of the humeral head to the glenoid can be judged statically and dynamically. Secondary signs of dislocation (Hill-Sachs lesions, joint effusion) are evident.
OBJECTIVE: To describe the normal anatomy and common abnormal changes of rotator cuff impingement and tears and recurrent anterior instability of shoulder joint in MRI pictures. METHODS: MRI was compared in 285 patients with shoulder diseases and 20 patients with symptomatic shoulder diseases. RESULTS: On oblique coronal image, the supraspinatus presented moderate signal intensity and low signal intensity in its tendon-muscle conjunction ranging from the humeral head to the greater tuberosity. The MRI manifestations of impingement lesion of the rotator cuff were as follows: high signal intensity of tendons, changes of their shapes, retraction of tendon-muscle conjunction, and muscle atrophy with high signal intensity. On T1-weighted axial image, the anterior and posterior glenohumeral labrum, the long head biceps tendon were displayed in low signal intensity. The anterior labrum manifested a sharp triangle contour and the posterior labrum a round one. The whole four muscles of the rotator cuff manifested on oblique sagital image. However, it was of less value in detecting the abnormalities of the rotator cuff and the glenohumeral labrum on sagittal imaging. The sensitivity in demonstrating rotator cuff complete tear was 95% for MRI and 91% for arthrography; the specificity was 88% for MRI and 100% for arthrography. The sensitivity and specificity of MRI were 96% and 75% for detecting glenoid labrum abnormalities, and 78% and 88% for detecting labrum tear in anterior recurrent dislocation of the shoulder. CONCLUSIONS: Magnetic resonance imaging with its excellent contrast resolution in multiple anatomic planes allows noninvasive visualization of bone and soft tissues in the rotator cuff and labrum.
BACKGROUND: Fluctuating asymmetry is assumed to measure individual and population level developmental stability. The latter may in turn show an association with stress, which can be observed through asymmetry-stress correlations. However, the recent literature does not support an ubiquitous relationship. Very little is known why some studies show relatively strong associations while others completely fail to find such a correlation. We propose a new Bayesian statistical framework to examine these associations RESULTS: We are considering developmental stability - i.e. the individual buffering capacity - as the biologically relevant trait and show that (i) little variation in developmental stability can explain observed variation in fluctuating asymmetry when the distribution of developmental stability is highly skewed, and (ii) that a previously developed tool (i.e. the hypothetical repeatability of fluctuating asymmetry) contains only limited information about variation in developmental stability, which stands in sharp contrast to the earlier established close association between the repeatability and developmental instability. CONCLUSION: We provide tools to generate valuable information about the distribution of between-individual variation in developmental stability. A simple linear transformation of a previous model lead to completely different conclusions. Thus, theoretical modelling of asymmetry and stability appears to be very sensitive to the scale of inference. More research is urgently needed to get better insights in the developmental mechanisms of noise and stability. In spite of the fact that the model is likely to represent an oversimplification of reality, the accumulation of new insights could be incorporated in the Bayesian statistical approach to obtain more reliable estimation.
External fixation of the pelvic girdle was used in a consecutive series of ten female patients suffering from suspected chronic instability of the sacro-iliac joint. The condition was attributed to pelvic relaxation after pregnancy in seven patients and to trauma in three. External fixation of the pelvis with a trapezoid frame reduced the average radiographic displacement of the symphysis from 5.0 to 2.4 mm in eight patients, relieved the dorsal pain in seven, and markedly improved walking ability in five. Seven of the ten patients were subsequently subjected to an anterior sacro-iliac joint arthrodesis in which square compression plates and autogenous bone grafts were used. At follow-up examination five of these patients were improved, and two unchanged. The results suggest that external fixation of the pelvis is useful in assessing painful sacro-iliac joint instability and should precede surgical intervention.
We present ultrasound investigation as a diagnostic tool for shoulder instability. The following structures are visible in the posterior transversal plane: subcutis, deltoid muscle, infraspinatus muscle, infraspinatus tendon, humeral head, scapula, dorsal glenoid rim, dorsal labrum, and the joint capsule. The relation of the humeral head to the glenoid can be judged statically and dynamically. Anterior and posterior instabilities and secondary signs of dislocation such as Hill-Sachs lesion and effusion can be seen. This technique is easy to learn. By comparing the injured with the normal shoulder the examiner can control his diagnosis. There is no need for positioning the patient in a special way. Sonographic evaluation is non-invasive and inexpensive.
Seventeen patients underwent posterior capsulotendinous tensioning procedures to eliminate recurrent posterior glenohumeral instability. Fourteen patients were evaluated an average of 44 months (range, 18 to 98) after surgery. The average patient age was 27 years. Before surgery, all patients were unable to perform their activities of daily living, occupational activities, and athletic activities. Preoperatively, the average pain rating score on a visual analog scale was 5 of 10 at rest and 9 of 10 with activities. Six patients had previous anterior reconstructions. After surgery, the average range of motion was 174 degrees of forward elevation and 69 degrees of external rotation; internal rotation was to the thumb level of T-8. No patient had a recurrence of posterior instability. After surgery, the average pain rating score was 2 of 10 at rest and 4 of 10 with activities. All patients improved after their operations, but four patients were minimally disabled from activities of daily living; six patients experienced shoulder fatigue at work; and four patients had difficulty with sports activities. Overall, 13 of the 14 patients were satisfied with their surgical procedures and their outcomes.
We report about a case of rupture of the pes anserinus insertion causing an anteriormedial knee instability grade () without rupture of the anterior cruciate ligament. This case demonstrates that a grade ()-instability can be caused without rupture of the cruciate ligaments just by the rupture of a so called "dynamic stabilisator" like the pes anserinus.
Of eithty-six patients with collateral ligament instability of the metacarpophalangeal joint of the thumb, sixty-six (77 per cent) had ulnar and twenty (23 per cent) had radial instability, while in addition twenty-four had fractures and twenty-nine had volar subluxation of the proximal phalanx. Of the sixty-nine patients operated on, sixty-five had an abnormality of the ulnar or radial collateral ligament proper or of its attachment; two, subluxation of the extensor pollicis longus; and two, stretching of the adductor expansion. Stability was restored by collateral ligament repair or reconstruction, by fixation of a fracture fragment with a Kirschner wire, or by arthrodesis in all but five thumbs. Of the five patients who did not have stability of the metacarpophalangeal joint following surgery, three had had the collateral ligament sutured more than three weeks after injury and two had had reconstruction of the collateral ligament using a tendon graft. Early surgical treatment is recommended for all patients with post-traumatic instability of the metacarpophalangeal joint greater than 45 degrees and for those with volar subluxation of the proximal phalanx or a displaced fracture of the base of the proximal phalanx. Collateral ligament repair is indicated for patients operated on within three weeks of injury, and reconstruction of the ligament by means of a tendon graft is recommended for those treated more than three weeks after injury.
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.
A case of tarsal tunnel syndrome following a reconstructive procedure with repair of chronic ankle instability using periosteal flap is reported. Two pathogenetic factors have to be discussed as possible causes for this complication. Dissection of the medial retinaculum was performed. With this procedure the patient is complaints could be removed.
Numerous reconstructive procedures have been described for the treatment of chronic instability of the distal radioulnar joint or instability of the stump of the resected distal ulna. This biomechanical study presents an evaluation of the three basic design types that have been used in reconstruction. The initial static stability provided by the reconstructions was tested and compared with the stability of the intact joint. Our findings show that all reconstructive procedures failed to restore natural joint stability. A radioulnar sling design was the most effective of the three types, whereas tenodesis procedures and ulnar collateral ligament reconstruction were much less effective in providing stability. We conclude that current designs have significant biomechanical shortcomings. On the basis of our observations during testing, we believe that improved designs will require an intra-articular reconstruction that more closely duplicates the biomechanical functions of the triangular fibrocartilage complex.
A novel animal model of osteoarthritis has been established for studies on the disease process as well as on mechanisms underlying the symptoms of osteoarthritis, principally pain and fatigue. The model is established by cutting the anterior cruciate ligament in the rat to introduce instability of the joint, removing the medial meniscus to induce further derangement of the joint, and exercising the rat on a modified rota-rod to generate weight-bearing mobility of the joint; this exercise can be regulated in terms of duration to govern severity of the model. The model exhibits many of the characteristics of osteoarthritis in humans, including bone and cartilage remodelling, infiltration of the joint tissues by immune cells and alterations in sensory mechanisms. This model will find application in development of novel interventions for the treatment of osteoarthritis and its symptoms as well as development of diagnostic tools for early detection.