Champ L Baker

Acute combined posterior cruciate and posterolateral instability of the knee

This report concerns 13 consecutive patients (13 knees) who underwent operative treatment for acute combined posterior cruciate and posterolateral instabil ity due to combined injury to the posterior cruciate ligament and the arcuate ligament complex. Our pur pose was to examine the method of diagnosis and the results in these patients. There were 12 males and 1 female (average age, 26 years). Five patients were injured in a motor vehicle accident, four in sports activ ities, and four in nonsports activities. The mechanism of injury was an anteromedial blow to the flexed knee in six patients, a fall onto the knee in two, and unknown in five patients. Eleven patients were available for fol low-up evaluation (average, 56 months), and in each the result was rated as good, fair, or poor. In 10 patients (90%) the results were rated as good subjectively, in 11 (100%) as good functionally, and in 8 (73%) as good objectively. Injury to both the posterior cruciate liga ment and the arcuate ligament complex can result from rotational force that can be due to a blow to the anteromedial aspect of the knee. Diagnosis can be made by a combined positive response to the posterior drawer test, the anterior drawer test performed with the tibia in internal rotation, the abduction and adduc tion stress tests performed with the knee in full exten sion, the posterolateral drawer test, and the external rotation-recurvatum test. In a knee with concomitant injury to the posterior cruciate ligament and the arcuate ligament complex that requires surgical repair, all in jured structures should be explored and repaired to ensure a subjectively, objectively, and functionally good result.

Calcific tendinitis of the shoulder

Calcific tendinitis of the shoulder is a process involving calcium deposition commonly in the rotator cuff tendons. It is a cell-mediated process that is often chronic in nature, but it is usually self-limiting with regard to its acute pain states. Nonoperative management is still the treatment of choice and is successful in up to 90% of patients. When conservative measures fail, a needling technique or surgical removal may be indicated; the trend is toward arthroscopic management. Acromioplasty should not be performed without radiographic signs of impingement. If a resulting large rotator cuff defect is found after removal of the calcific deposit, it may be worthwhile to close the defect arthroscopically with suture to prevent cuff tear progression and to promote healing.

Comparison of Lateral Ankle Ligamentous Reconstruction Procedures

The static restraints of various surgical procedures for chronic lateral ankle instability were compared. Forty cadaveric ankles were divided equally into the follow ing five groups: 1) ankles with intact anterior talo fibular and calcaneofibular ligaments, 2) ankles with incised anterior talofibular and calcaneofibular liga ments, 3) ankles with Chrisman-Snook procedure, 4) ankles with Watson-Jones procedure, or 5) ankles with modified Broström procedure. All ankles were placed in a mechanical apparatus for anterior drawer stress and inversion stress tests. After each applica tion of force, a radiograph of the ankle joint was taken, and the anterior talar displacement and the ta lar tilt angle were measured. All procedures reduced anterior drawer and talar tilt when compared with the ankles with incised anterior talofibular and calcaneofibular ligaments. Significant differences were found among the groups for both in version and anterior drawer stress at all forces, except for the third and fourth groups. The modified Broström group had the least amount of anterior talar displace ment and talar tilt angle at all forces. There were no significant differences between the Watson-Jones and the Chrisman-Snook procedures in anterior talar dis placement and talar tilt. The modified Broström proce dure produced a greater mechanical restraint than either of the other procedures.

Future Treatment of Osteoarthritis

Osteoarthritis represents an advanced stage of disease progression caused in part by injury, loss of cartilage structure and function, and an imbalance in inflammatory and noninflammatory pathways. The burden of this disease will increase in direct proportion to the increase in the older adult population. Research on current and experimental treatment protocols are reviewed, including the effect of hyaluronic acid in both in vitro and in vivo studies, autologous chondrocyte and osteochondral plug implantation, and gene therapy. Disease-modifying osteoarthritis drugs and in vivo studies of glucosamine and chondroitin sulfate are reviewed.

Popliteal cyst: a surgical approach.

Twenty-nine adult patients (30 knees) who failed conservative treatment had surgical excision of a non-rheumatoid cyst. To determine the effectiveness of this surgical procedure, we reviewed the cases of 24 patients (25 knees) who were available for subjective and objective follow up. Twenty of the 25 knees (80%) were rated excellent or good. Three knees had fair results. Two knees continued to have problems and ultimately underwent total knee replacement for degenerative arthritis.

Current concepts in ankle arthroscopy

Ankle arthroscopy has rapidly become an important diagnostic and therapeutic procedure. Currently, indications for operative arthroscopy include transchondral talar dome fractures, acute articular fractures with hemarthrosis, posttraumatic synovitis, loose bodies, inflammatory synovitis, degenerative joint disease, and soft tissue impingement. Diagnostic arthroscopy is indicated for the patient with a chronically painful, symptomatic ankle when nonoperative treatment has failed and other measures have failed to produce a diagnosis. Three standard portals are used for routine ankle arthroscopy and allow a systematic examination of the joint. Mechanical distraction may be required to visualize the entire joint, the tight ankle, the ankle with posterior lesions, or to allow operative instruments to be introduced. The use of lasers in arthroscopy has yet to be clearly defined. The small size of the laser is an advantage in the ankle, but cost remains a disadvantage. Advances in technique and equipment will continue to expand the indications for this procedure.

Intraarticular ACL reconstruction using the patellar tendon : arthroscopic technique

Endoscopic ACL reconstruction using the bone-patellar tendon-bone autograft has been shown to have good, reliable results. The procedure provides excellent reproducible fixation immediately and allows for early aggressive rehabilitation that includes range of motion, strengthening, and rapid return to sports.

Deltoid Muscle Pressures During Arthroscopic Rotator Cuff Repair

The purpose of this study was to investigate deltoid compartment pressures during arthroscopic rotator cuff repair using modern pressure pumps to achieve visualization. Twelve patients undergoing arthroscopic rotator cuff repairs were monitored for deltoid compartment pressure changes intraoperatively. Pre-, intra-, and postoperative intramuscular pressures were recorded. All patients demonstrated varying degrees of swelling due to fluid extravasation. Swelling was qualified as mild, moderate, or severe by clinical assessment and quantified objectively using a pressure monitor to record deltoid compartment pressures. Clinically, severe swelling occurred in 4 patients, all of whom underwent procedures lasting longer than 90 minutes. Objectively, no patient had evidence of dangerously elevated pressure measurements. The mean increase in compartment pressures was 9 mm Hg. All patients were treated and discharged as outpatients. No patient required more than oral narcotic analgesics for postoperative pain control beyond the postanesthesia care unit stay. Arthroscopic rotator cuff repair may lead to clinically impressive swelling, but within the current study group, no evidence existed of clinically significant, persistent elevation of deltoid compartment measures using current arthroscopic techniques and arthroscopic pump systems. However, caution should be observed with regard to extended operative times and elevation of pump pressures.