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PubMed2001

Chondral and osteochondral injuries. Diagnosis and management.

Osteochondral lesions are relatively common and usually occur as a result of trauma. They often are unrecognized acutely and lead to osteochondral defects and eventually osteoarthritis. Detection of these lesions has been aided by bone scan, CT, and MR imaging. Acute osteochondral fragments can be replaced and internally fixed. Chronic osteochondral defects can be treated with several methods designed to stimulate healing by either fibrocartilage or healing by transplantation of bone and cartilage or cartilage alone. The goal of all treatment methods is to provide a stable, congruent joint surface, restore function, and prevent the evolution of osteoarthritis in the injured joint.

Algorithms↗
PubMed2006

Sporadic Larsen syndrome in a preterm female originally diagnosed as positional deformities due to oligohydramnios.

Few reports describe incidental prenatal diagnosis of sporadic Larsen syndrome by ultrasound, but none of these discuss coincidental oligohydramnios or an association with fetal growth restriction. A 28-year-old woman had prolonged rupture of membranes causing marked oligohydramnios at 32 weeks gestation in her first pregnancy. Labor was induced by vaginal prostaglandins and oxytocin infusion after dexamethasone administration because of concern about placental abruption. She delivered vaginally a live female infant weighing 1960 g (< 10th percentile) with multiple skeletal malformations and characteristic facies originally suspected as positional. Newborn x-rays, however, established the diagnosis of Larsen syndrome with bilateral dislocations of the hips, knees (genu recurvatum), and ankles (club foot). The neonatal karyotype was 46,XX. Parental examination and family history were unremarkable. The newborn did well with bilateral lower extremities cast. Postnatal diagnosis of Larsen syndrome should be suspected in neonates with multiple skeletal abnormalities following oligohydramnios.

Facies↗
PubMedDate not supplied

Musculoskeletal manifestations of Hurler syndrome: long-term follow-up after bone marrow transplantation.

Bone marrow transplantation (BMT) is effective in ameliorating many of the clinical manifestations of Hurler syndrome. However, long-term data on the natural history of the musculoskeletal disorders of Hurler syndrome after BMT are limited. The authors report the orthopaedic outcomes in seven patients with Hurler syndrome who were successfully engrafted between 1990 and 1999, and have been followed for a mean of 7.6 years since transplantation. Medical records, clinical examinations, and imaging studies were reviewed to assess the development and management of hip dysplasia, genu valgum, spine abnormalities, hand abnormalities, and joint range of motion. BMT does not appear to alter the natural history of the musculoskeletal disorders in Hurler syndrome, although there may be a beneficial effect on upper extremity joint mobility.

Bone Diseases, Developmental↗
PubMed2003

Thoracic spinal cord injury without radiographic abnormality in a skeletally mature patient: a case report.

STUDY DESIGN: A case of thoracic spinal cord injury without radiographic abnormality in a skeletally mature patient is reported. OBJECTIVES: To report, for the first time in the literature, a case of thoracic spinal cord injury without radiographic abnormality or any ligamentous injury in a skeletally mature patient, and to propose a unique mechanism of spinal cord traction injury resulting from associated bilateral high-energy lower limb injuries. SUMMERY OF BACKGROUND DATA: Thoracic spinal cord injury without radiographic abnormality is extremely uncommon in skeletally mature patients. Hyperflexion with an associated distraction force usually produces the spinal cord injury, which is associated with posterior ligamentous injury of the spine. In the only reported case of thoracic spinal cord injury without radiographic abnormality in a skeletally mature patient to date (1993), despite the absence of evidence showing bony injury associated with cord damage on plain radiographs and computed tomograms, the magnetic resonance image demonstrated significant injury to the posterior ligamentous structures of the spine. Thoracic spinal cord injury in a skeletally mature patient without associated bony and ligamentous injury has never before been reported. METHODS: A 17-year-old skeletally mature motorcyclist was involved in a road traffic accident and sustained multiple injuries. Clinical examination showed tenderness over L1 and L2 vertebrae with complete loss of sensation and motor power below L2. In addition, the patient also sustained a stable pelvic fracture; fracture of the right acetabulum; open dislocation of the right knee with complete disruption of both cruciate ligaments, the posteromedial capsule, and the medial collateral ligament; open fracture of the left tibia and fibula; displaced fracture of the medial condyle of the left femur; fracture of the right distal radius; and fracture of the right proximal humerus. The plain radiographs of the whole spine and computed tomography scanning of the thoracolumbar spine showed no evidence of bony injury. The contemporary magnetic resonance image scanning of the entire spine showed disruption of the spinal cord from T10 downward, with patchy high signal in the cord and loss of normal architecture. After appropriate management of the associated limb injuries, the patient was transferred to the regional spinal unit for rehabilitation. RESULTS: Thoracic spinal cord injury in a skeletally mature patient occurred in the absence of associated bony and ligamentous injury, and probably resulted from a longitudinal traction force transmitted through the sciatic nerves to the spinal cord as a result of associated high-energy bilateral lower limb injuries. CONCLUSIONS: A rare case of thoracic spinal cord injury without radiographic abnormality manifested as a result of traction injury to the sciatic nerves caused by bilateral violent lower limb injuries in a skeletally mature patient is presented. To the best of the authors' knowledge, such a case has not been reported previously.

Accidents, Traffic↗
PubMed2001

Results of operative fixation of unstable ankle fractures in geriatric patients.

It is widely accepted that operative fixation of unstable ankle fractures yields predictably good outcomes in the general population. The current literature, however reports less acceptable results in the geriatric population age 65 years and older. The current study analyzes the outcome of the surgical treatment of unstable ankle fractures in patients at least 65 years old. Twenty three patient over 65 years old were surgically treated after sustaining 21 (91%) closed and 2 (9%) open grade II unstable ankle fractures. Fractures were classified according to the Danis-Weber and Lauge-Hansen schemes. Fracture type was predominantly Weber B (21/23, 91%), or supination external rotation stage IV (21/23, 91%). Fracture union rate was 100%. There were three significant complications including a lateral wound dehiscence with delayed fibular union in an open fracture dislocation, and two below knee amputations, neither of which was directly related to the fracture treatment. There were three minor complications; one superficial wound infection and two cases of prolonged incision drainage, all of which resolved without further surgical intervention. Complications were associated with open fractures and preexisting systemic disease. These results indicate that open reduction and internal fixation of unstable ankle fractures in geriatric patients is an efficacious treatment regime that with results that are comparable to the general population.

Age Factors↗
PubMed2003

Impact of patellofemoral design on patellofemoral forces and polyethylene stresses.

BACKGROUND: The patellofemoral joint is a complex articulation because it relies mainly on soft-tissue constraints for stable tracking. The presence of a functioning posterior cruciate ligament and the design parameters of a total knee arthroplasty, such as trochlear groove alignment and cam-post configuration, can have a major effect on patellar biomechanics. METHODS: A finite element model of a knee implanted with femoral, tibial, and patellar components was generated. The model was validated by experimental testing of three cadaver knees implanted with a total knee prosthesis and a patellar force transducer. Two femoral component designs with different valgus angles of the trochlear groove (0 degrees and 7 degrees ) were studied. The effects of femoral rollback, rotation of the femoral component, medialization of the patellar implant, and alignment of the trochlear groove on patellar forces were then analyzed. RESULTS: A consistent reduction of up to 7% in patellofemoral forces was seen with progressive magnitudes of femoral rollback. The 0 degrees -aligned trochlear groove generated some lateral patellofemoral shear force throughout knee flexion. The 7 degrees -aligned trochlear groove generated medial shear force at flexion angles of <20 degrees and lateral shear force at flexion angles of >20 degrees. A more medial patellar component position reduced peak lateral shear forces by up to 10 to 15 N. However, a corresponding increase in medial shear forces was seen. CONCLUSIONS: This model predicted substantial reduction in patellofemoral lateral shear forces with a medialized patellar component or with external rotation of the femur. The model supported the hypothesis that femoral rollback reduces patellofemoral forces by improving the efficiency of the extensor mechanism. CLINICAL RELEVANCE: Patellofemoral complications after total knee arthroplasty include anterior knee pain, patellar subluxation and dislocation, abnormal polyethylene wear and damage, and loosening. There is a wide variation in the design features of current total knee prostheses, such as the sagittal radius, depth, and orientation of the trochlear groove of the femur and the geometry of the patellar component surface. The finite element model used in the present study can provide insight into the effects of design parameters on patellofemoral forces and on local contact stresses.

Arthroplasty, Replacement, Knee↗
PubMed1989

Cross-country skiing injuries and biomechanics.

Cross-country skiing exercises most of the joints, muscles and tendons in the body giving the skier an all around workout. This, in combination with a low incidence of injury, makes cross-country skiing an ideal recreational and competitive sport. The new skating techniques developed during the last decade have resulted in greater velocity. The maximum speed during the diagonal stride technique is 6 m/sec compared to 8 to 9 m/sec when skating and double poling. Top-level skiers today use strong and ultra light skis of fiberglass and graphite. The ski weight is less than 500g. Today's skating technique does not require any waxing and only the cambered portion of the ski is waxed when performing the diagonal stride. The preparation of the ski course has improved with the development of special track machines. This allows top-level skiers to reach 60 to 80 km/h on downhill slopes, which has resulted in an increased risk of injury. Because cross-country skiing takes place wherever snow is available, it is difficult to establish accurate injury rates in comparison to alpine skiing which is performed on very specialised terrain at ski areas. Studies estimate the cross-country ski injury rate in Sweden to be around 0.2 to 0.5 per thousand skier days. A prospective study of cross-country ski injuries conducted in Vermont revealed an injury rate of 0.72 per thousand skier days. 75% of the injuries sustained by members of the Swedish national cross-country ski team during 1983 and 1984 were overuse injuries while 25% resulted from trauma. The most common overuse injuries included medial-tibial stress syndrome, Achilles tendon problems and lower back pain. Most common among traumatic injuries were ankle ligament sprains and fractures, muscle ruptures, and knee ligament sprains. Shoulder dislocation, acromioclavicular separation and rotator cuff tears are not infrequent in cross-country skiing. Injuries to the ulnar collateral ligament of the metacarpal phalangeal joint of the thumb (Stener's lesion) is the most common ski injury involving the upper extremity. Cross-country skiers 16 to 21 years of age complained more frequently of mild lower back pain than similarly aged non-skiers. This may result from repetitive hyperextension motions during the kick phase and the recurring spinal flexion and extension during the double poling phase. Repeated slipping on hard and icy tracks infrequently produce partial tears or microtrauma in the muscle tendinous units of the groin.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMedDate not supplied

Arthrogryposis and amyoplasia.

Arthrogryposis (multiple congenital joint contractures) is an uncommon problem. Because there are many causes, correct diagnosis is important to predict the natural history and determine appropriate treatment. Inconsistent terminology has caused confusion about both diagnosis and treatment. Amyoplasia, the most common type of arthrogryposis, is characterized by quadrimelic involvement and replacement of skeletal muscle by dense fibrous tissue and fat. Early physical therapy and splinting may improve contractures, but surgical intervention is often necessary. Aggressive soft-tissue releases in addition to casting may improve joint position. In more severe contractures, osseous surgery also may be needed. Deformity recurrence is common, particularly in skeletally immature patients.

Arthrogryposis↗
PubMed1989

Open joint injuries. Classification and treatment.

Experience with wounds involving the major joints of the lower extremity suggests that the extracapsular soft tissues and the intracapsular structures should be considered individually to assess accurately the magnitude of injury and to provide a prognosis. A classification scheme is proposed to characterize the areas and types of injury. Type I open joint injuries are single penetrations without extensive soft-tissue damage, permitting uncomplicated joint and wound closure. Type II injuries are single or multiple penetrations with extensive soft-tissue disruptions (flaps, avulsions, degloving), often requiring secondary operations to attain closure. Type III injuries are open periarticular fractures with extension through the adjacent intraarticular surface. Type IV injuries are open dislocations or those with associated nerve or vascular injury requiring repair. The extent of intraarticular injury further subdivides Types I, II, and III. The prognosis for functional impairment correlates with the severity of injury. The cornerstones for successful management are debridement, antibiotic therapy, properly timed and performed joint closure, and aggressive treatment of the associated bony injury.

Adult↗
PubMed1989

[Restorative-reconstructive surgery of the sequelae of osteomyelitis of the lower extremities].

Results of reconstructive-restorative operations on 40 patients with sequellae of acute hematogenic osteomyelitis of lower extremities are described. Most frequent of them are pathologic dislocations, axial extremity, ankylosis and contractures of large vessels in a faulty position. Extrafocal compression-distraction osteosynthesis after Ilizarov was used. Little-traumatic character of the method, stable fixation and early functional loading gave smooth course of the postoperative period and good anatomo-functional results in most of the patients.

Adolescent↗