Garron G. Weiker

Prospective study of osseous, articular, and meniscal lesions in recent anterior cruciate ligament tears by magnetic resonance imaging and arthroscopy

Fifty-four patients with anterior cruciate ligament tears that were arthroscopically reconstructed within 3 months of initial injury were prospectively evaluated. Patients with grade 3 medial collateral ligament, lateral collateral ligament, or posterior cruciate ligament tears were excluded. Eighty percent of our patients had a bone bruise present on the magnetic resonance image, with 68% in the lateral femoral condyle. Two of the latter findings—an abnormal articular cartilage signal (P = 0.02) and a thin and impacted subchondral bone (P = 0.03)—had a significant relationship with injury to the overlying articular cartilage. Meniscal tears were found in 56% of the lateral menisci and 37% of the medial menisci. A significant association was present between bone bruising on the lateral femoral condyle and the lateral tibial plateau (P = 0.02). Results of our study support the concept that the common mechanism of injury to the anterior cruciate ligament involves severe anterior subluxation with im paction of the posterior tibia on the anterior femur. Determination of the significance of bone bruising, ar ticular cartilage injury, or meniscal tears will require a long-term followup that includes evaluation for arthritis, stability, and function. These 54 patients represent the first cohort evaluated in this ongoing prospective clinical study.

Effect of an Ankle Orthosis and Ankle Ligament Anesthesia on Ankle Joint Proprioception

The purposes of this study were to determine the effect of a rigid ankle orthosis (Aircast Air-Stirrup) and lateral ankle ligament anesthesia on ankle joint proprioception. Twelve noninjured subjects attempted to match nine reference ankle joint positions with their eyes closed before and after application of the ankle brace and be fore and after one or two of the lateral ankle ligaments (anterior talofibular and calcaneofibular) were anesthe tized. Three-dimensional ankle joint orientations were recorded with a Motion Analysis system. No significant differences in the constant, variable, or absolute error were seen between subjects in the non- anesthetized and anesthetized conditions (P > 0.05), regardless of whether one or two ligaments were anes thetized. Thus, it appears that ligament mechanorecep tors contributed little to ankle joint proprioception, and that the afferent feedback from skin, muscle, and other joint receptors was adequate for the positioning task of the present study. Both the variable and absolute error in matching the reference positions were significantly less with the orthosis than without (P < 0.05). Applica tion of an orthosis may increase the afferent feedback from cutaneous receptors in the foot and shank, which may in turn lead to an improved ankle joint position sense.

Posterior shoulder instability Surgical versus conservative results with evaluation of glenoid version

We conducted a retrospective study on 50 patients with recurrent posterior shoulder instability. Twenty- five patients were treated conservatively with a specific rehabilitation program strengthening the rotator cuff. The other 25 patients, who did not improve with reha bilitation, underwent surgical reconstruction, the major ity of these being soft tissue repairs. Recurrence in the surgically treated group averaged 72% while that in the conservatively treated group was 96%. However, 50% of those patients treated surgically and 68% of those treated conservatively felt their symptoms were im proved. In view of the high recurrence rate with soft tissue reconstruction, computed tomography scans were ob tained to evaluate glenoid version. Those patients with posterior shoulder instability were found to have in creased glenoid retroversion when compared to an uninjured population (P < 0.05). Our conclusions based on this study were that 1) specific therapy in the form of rotator cuff strengthening should be the initial form of treatment in patients with posterior shoulder insta bility, 2) soft tissue surgery has a high rate of recur rence, 3) the return to sports is variable, 4) there appears to be an increased incidence of glenoid retro version in this patient population, and 5) the incidence of posttraumatic arthritis is low.

Menstrual Abnormalities, Nutritional Patterns, and Body Composition in Female Classical Ballet Dancers

In brief: Classical ballet is a demanding discipline that until recently has been largely ignored by the medical and exercise communities. The authors studied the nutritional habits of 34 high-level classical ballet dancers during three days of a typical rehearsal week and found that they consumed only 71.6% of the recommended daily allowance for nutrients. Their average percent body fat was 16.9%. Many (17) had menstrual abnormalities, 15 had secondary amenorrhea, and 11 cited irregularities they felt were directly due to dancing. No statistical correlation could be found between the reported menstrual abnormalities and percent body fat or the age they began training.

The predictive value of radiographs in the evaluation of unilateral and bilateral anterior cruciate ligament injuries

A review of 250 cases of surgical reconstruction of the anterior cruciate ligament identified 24 patients with bilateral complete tears of the anterior cruciate liga ment. Twenty of these patients had previous recon struction of one anterior cruciate ligament before rup ture of the opposite ligament. Twelve injuries occurred during the same activity that was responsible for the initial opposite injury. The average time between sur gical reconstruction and rupture of the opposite liga ment was 29.3 months (range, 3 to 103). No significant demographic differences existed between patients with unilateral or bilateral ruptures of the anterior cruciate ligament. Standardized measurements of intercondylar notch height and width and medial and lateral femoral condyle height and width were performed on routine notchview radiographs of 31 knees of patients with bilateral inju ries, 30 with unilateral injury, and 30 with no anterior cruciate ligament injury. Statistical analysis revealed no significant differences between the three groups when comparing absolute measures or any of eight mathe matical ratios calculated from these measurements. We concluded that measurements of the intercondylar notch made from radiographs may not be reliable pre dictors of injury to the anterior cruciate ligament. We found no significant clinical or demographic differences between patients with unilateral or bilateral complete ruptures of the anterior cruciate ligament.

Technique and ground reaction forces in the back handspring

The ground reaction forces at the hand that produced compression forces and varus/valgus moments at the elbow joint during the double-arm support phase of the back handspring were studied. The relationship of tech nique, namely elbow joint flexion, to these forces were also studied. Compression forces and forces producing valgus moments have been implicated in overuse inju ries to the elbow joint. Video and force plate analysis of six young female gymnasts showed that 1) the elbow joint flexed during the double-arm support phase, and 2) the reaction forces at the hand produced large compression forces (an average of 2.37 times body weight) and sizable valgus moments at the elbow (an average of 0.03 times body weight times body height). The combination of these forces may contribute to the occurrence of lateral compression injuries of the elbow joint (e.g., osteochondritis dissecans of the capitellum). Correlations of measures of elbow angle and measures of reaction force showed that large elbow flexions may protect the elbow from large valgus moments.

Injuries in Club Gymnastics.

In brief: There is relatively little information about injuries to club gymnasts. Therefore, the author conducted a statistical prospective study of the epidemiology of this group, following 873 club-level gymnasts for a nine-month season to establish injury incidence and related trends. Although the number of subjects was too small for statistical validity, many trends were identified. It seems that club gymnastics does not have an excessively high injury rate and that further data should make it possible to decrease the number of injuries.

Serum lidocaine and bupivacaine levels in local technique knee arthroscopy

We investigated serum levels of lidocaine and bupiva caine following their intraarticular and subcutaneous injection for anesthetic effect in local technique knee arthroscopy. Fifteen patients scheduled for knee ar throscopy, but who were otherwise healthy, were stud ied. Following preparation of the knee, 25 cc of 1% lidocaine with epinephrine (1:100,000) and 25 cc of 0.25% bupivacaine were instilled into the knee joint. An additional 40 cc of the combined solution was used to anesthetize four arthroscopic portal sites from the skin into the joint capsule. The arthroscopic procedure was then performed. We took blood samples 5, 15, 30, 60, and 120 minutes after intraarticular injection. High- performance liquid chromatography was used to deter mine serum values of the agents. Levels of the anes thetic agents in all of the patients at all time intervals were well within the ranges considered safe. Patient surveys of these and 49 other patients indicated a high degree of satisfaction with the technique. No compli cations from the anesthetic agents were noted at our hospital in over 500 similar cases. We conclude that local anesthesia as described here is a safe and effec tive alternative to conventional anesthetic techniques. Additionally, it can save time in the operating room and reduce patient costs.

Isobutyl cyanoacrylate as a soft tissue adhesive. An in vitro study in the rabbit Achilles tendon

Cyanoacrylates (CAs) are biodegradable, bacteriostatic, and hemostatic adhesives. CAs have been used in medical applications, but with adverse effects, including excessive inflammatory reaction and neural toxicity. Isobutyl CA (ICA) appears more biocompatible, with a long half-life that may be ideal for a soft tissue adhesive. The rabbit Achilles tendon was chosen to test (ICA), and a special muscle-freezing clamp to test this model was designed. The tendons were sharply cut 2 cm proximal to their insertion and repaired in four groups. They were tested to failure on an Instron machine. The breaking strength of the repairs was then noted. Also, the breaking strength of several suture materials was tested. Four Achilles tendon repair groups were evaluated: ICA alone 9.03 newtons (NTS); 4-0 silk Kessler stitch, mean 12.9 NTS; Kessler stitch plus three simple stitches, mean 23.0 NTS; and a combination of (a) and (c)--i.e., suture and adhesive, mean 40.2 NTS. The intact Achilles tendon was tested with an average breaking strength of 317 NTS. The muscle-freezing clamp facilitated reasonable testing of this tendon repair. ICA alone exhibits reasonable strength in vitro and in combination with suture provides a stronger initial repair than either suture or adhesive alone.

Efficacy of Intermittent Epidural Morphine Following Posterior Spinal Fusion in Children and Adolescents

Postoperative pain is a distressing and disabling feature of scoliosis surgery. Epidural morphine has recently been advocated to reduce the frequency and severity of postoperative pain in adults. A retrospective study of 35 patients was conducted to determine whether epidural administration of morphine is useful in the management of postoperative pain in children and adolescents following posterior spinal fusion. The derived data included dose and frequency of narcotic administration on the day of surgery and during the subsequent three days. On the first postoperative day, the total morphine given averaged only 16.4 mg in patients receiving epidural morphine compared to 27 mg in those receiving only conventional parenteral morphine. Similar significant differences persisted through the second postoperative day. Intermittent epidural injection of small doses of morphine can give satisfactory and prolonged analgesia for early postoperative pain management.