Helene Pavlov

Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament.

The results of reconstruction of the anterior cruciate ligament with the central third of the patellar ligament as a free, autogenous, non-vascularized graft were retrospectively reviewed at our institution. Eighty reconstructions in seventy-nine patients were evaluated after a minimum of two years. In forty-eight (60 per cent) of the knees, the reconstruction was augmented with an extra-articular lateral sling of iliotibial band. The patients were evaluated with a physical examination, a KT-1000 arthrometer, radiographs, a subjective questionnaire, and a revision of the scale of The Hospital for Special Surgery for rating ligaments. Postoperatively, seventy-six (95 per cent) of the eighty knees no longer gave way, and the pivot-shift test was negative in sixty-seven (84 per cent) of the knees. The average score on the ligament-rating scale was 93 points. All of the patients who had clinical instability at the time of the most recent follow-up had associated ligamentous instability that had not been appreciated or addressed at the time of reconstruction. Arthrometric evaluation revealed that the laxity differed by three millimeters or less from that of the untreated knee in sixty (76 per cent) of the treated knees. In the patient who had bilateral reconstruction, the laxity was the same in both knees. Seventeen patients, who had more than three millimeters of translation, also had additional related ligamentous instability, most commonly posterolateral instability and insufficiency of the medial collateral ligament. We think that major associated ligamentous instability predisposes the reconstruction to failure and should be corrected in conjunction with the reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Minimally invasive total knee replacement through a mini-midvastus incision : an outcome study

Total knee replacement traditionally has been done through an anterior incision approximately 18 cm long, using a capsular incision that separates the interval between the rectus femoris and vastus medialis musculature. Although giving excellent exposure, this incision also disrupts the suprapatellar pouch and may lead to adhesions and difficulty with rapidly regaining flexion. It is hypothesized that, by using a more minimally invasive incision, there will be a more rapid return of flexion and the patient will require fewer narcotic medications postoperatively. This retrospective review compared 32 total knee replacements done through a minimally invasive mini-midvastus approach with 26 total knee replacements done through the standard medial parapatellar approach. Preoperative Knee Society scores and postoperative functional outcomes were compared. Postoperative flexion was measured daily during hospitalization and at a 6-week and 3-month followup. Pain was assessed by a visual analog scale and the amount of pain medication used during hospitalization. Implant position was measured. The MIS group had an average skin incision length of 12.8 cm. Passive flexion on a daily basis was significantly higher in the MIS group compared with the standard group. At 6 weeks postoperatively, the change in Knee Score was statistically higher in the MIS group and the average visual analog pain score and the total amount of pain medication was lower. The radiographic alignment and position of all the components was normal in all patients in both groups. The limited disruption of the extensor mechanism results in more rapid restoration of the quadriceps muscle control.

Natural history of the posterior cruciate ligament-deficient knee.

This paper documents the clinical course of the posterior cruciate ligament-deficient knee. By obtaining an understanding of the natural history of this lesion, the indications for surgical repair, reconstruction, and conservative treatment will be more clearly defined, and the clinician will be able to more critically evaluate the results of both acute repair and reconstruction of this ligament. Forty-three patients with an average interval of 6.3 years (range, one to 37 years) between injury and evaluation were included in this study. Fourteen patients had a straight unidirectional posterior instability and 29 had a combined multidirectional instability. The follow-up evaluation included functional assessment, physical and roentgenographic evaluation, arthrometric laxity measurement, and isokinetic dynametric testing of quadriceps function. Statistical treatment of the data, utilizing both nonparametric methods and logistic modeling, clearly delineated the natural history of the injury to the posterior cruciate ligament (PCL). It was established that the functional outcome can be predicted on the basis of the instability type. Specifically, those knees with PCL disruption without associated ligamentous laxity will probably remain symptom-free. However, when PCL disruption is associated with combined instabilities, a less than desirable functional result will probably occur. Application of logistic modeling to the data demonstrated that the functional result was not due to the type of instability per se, but rather to associated factors, i.e., chondromalacia of the patella, meniscal derangement, quadriceps atrophy, or degenerative changes. A direct correlation has been established between combined multidirectional instability and the occurrence of those associated secondary problems resulting in the patients complaints and functional disability.(ABSTRACT TRUNCATED AT 250 WORDS)

The Relationship of Developmental Narrowing of the Cervical Spinal Canal to Reversible and Irreversible Injury of the Cervical Spinal Cord in Football Players. An Epidemiological Study

An evaluation of forty-five athletes who had had an episode of transient neurapraxia of the cervical spinal cord revealed a consistent finding of developmental narrowing of the cervical spinal canal. The purpose of the present epidemiological study was to determine the relationship, if any, between a developmentally narrowed cervical canal and reversible and irreversible injury of the cervical cord with use of various cohorts of football players as well as a large control group. Cohort I comprised college football players who were asymptomatic and had no known history of transient neurapraxia of the cervical cord. Cohort II consisted of professional football players who also were asymptomatic and had no known history of transient neurapraxia of the cervical cord. Cohort III was a group of high-school, college, and professional football players who had had at least one episode of transient neurapraxia of the cervical cord. Cohort IV comprised individuals who were permanently quadriplegic as a result of an injury while playing high-school or college football. Cohort V consisted of a control group of male subjects who were non-athletes and had no history of a major injury of the cervical spine, an episode of transient neurapraxia, or neurological symptoms. The mean and standard deviation of the diameter of the spinal canal, the diameter of the vertebral body, and the ratio of the diameter of the spinal canal to that of the vertebral body were determined for the third through sixth cervical levels on the radiographs for each cohort. In addition, the sensitivity, specificity, and positive predictive value of a ratio of the diameter of the spinal canal to that of the vertebral body of 0.80 or less was evaluated. The findings of the present study demonstrated that a ratio of 0.80 or less had a high sensitivity (93 per cent) for transient neurapraxia. The findings also support the concept that symptoms may result from a transient reversible deformation of the spinal cord in a developmentally narrowed osseous canal. The low positive predictive value of the ratio (0.2 per cent) however, precludes its use as a screening mechanism for determining the suitability of an athlete for participation in contact sports. Developmental narrowing of the cervical canal in a stable spine does not appear to predispose an individual to permanent catastrophic neurological injury and therefore should not preclude an athlete from participation in contact sports.

Transtibial Versus Anteromedial Portal Drilling for Anterior Cruciate Ligament Reconstruction: A Cadaveric Study of Femoral Tunnel Length and Obliquity

PURPOSE To compare the obliquity and length of femoral tunnels prepared with transtibial versus anteromedial portal drilling for anterior cruciate ligament (ACL) reconstruction and identify potential risks associated with the anteromedial portal reaming technique. METHODS We used 18 human cadaveric knees (9 matched pairs) without ACL injury or pre-existing arthritis for the study. Femoral tunnels for ACL reconstruction were prepared by either a transtibial (n = 6) or anteromedial portal (n = 12) technique. For the anteromedial portal technique, a guidewire was advanced through the medial portal in varying degrees of knee flexion (100 degrees [n = 4], 110 degrees [n = 4], or 120 degrees [n = 4]) as measured with a goniometer. By use of a 6-mm femoral offset guide, two 6-mm femoral tunnels were reamed with the guide placed (1) as far posterior and lateral in the notch as possible and (2) as far medial and vertical in the notch as possible to define the range of maximal and minimal achievable coronal obliquity for each technique. All knees were imaged with high-resolution, 3-dimensional fluoroscopy to define (1) coronal tunnel obliquity relative to the lateral tibial plateau, (2) sagittal tunnel obliquity relative to the long axis of the femur, (3) intraosseous tunnel length, and (4) the presence of posterior cortical wall blowout. Data analysis was performed with a paired t-test and repeated-measures analysis of variance, with P < .05 defined as significant. RESULTS Preparation of a vertical tunnel was possible with both transtibial and anteromedial portal drilling. The maximal achievable coronal obliquity, however, was significantly better with an anteromedial portal compared with transtibial drilling. However, 7 of 36 tunnels (19.4%) showed violation of the posterior tunnel wall, and all of these cases occurred with the anteromedial portal drilling technique. In addition, 1 of 6 oblique femoral tunnels (16.7%) drilled with the transtibial technique and 5 of 12 oblique femoral tunnels (41.7%) drilled with the anteromedial portal had an intraosseous length less than 25 mm. Increasing knee flexion with anteromedial portal drilling was associated with a significant reduction in tunnel length, increase in coronal obliquity, increase in sagittal obliquity, and increased risk of posterior wall blowout (P < .05). CONCLUSIONS The anteromedial portal technique allows for slightly greater femoral tunnel obliquity compared with transtibial drilling. However, there is a substantially increased risk of critically short tunnels (<25 mm) and posterior tunnel wall blowout when a conventional offset guide is used. Increasing knee flexion with anteromedial portal drilling allows for greater coronal obliquity of the femoral tunnel but is accompanied by a greater risk of critically short tunnels and posterior wall compromise. CLINICAL RELEVANCE Our findings provide insight into the potential risks and advantages of a transtibial versus an anteromedial femoral tunnel drilling technique in ACL reconstruction.

Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain.

Plantar lateral foot pain may be caused by various entities and the painful os peroneum syndrome (a term coined by the authors) should be included in the differential diagnosis. Painful os peroneum syndrome results from a spectrum of conditions that includes one or more of the following: (1) an acute os peroneum fracture or a diastasis of a multipartite os peroneum, either of which may result in a discontinuity of the peroneus longus tendon; (2) chronic (healing or healed) os peroneum fracture or diastasis of a multipartite os peroneum with callus formation, either of which results in a stenosing peroneus longus tenosynovitis; (3) attrition or partial rupture of the peroneus longus tendon, proximal or distal to the os peroneum; (4) frank rupture of the peroneus longus tendon with discontinuity proximal or distal to the os peroneum; and/or (5) the presence of a gigantic peroneal tubercle on the lateral aspect of the calcaneus which entraps the peroneus longus tendon and/or the os peroneum during tendon excursion. Familiarity with the various clinical and radiographic findings and the spectrum of conditions represented by the painful os peroneum syndrome can prevent prolonged undiagnosed plantar lateral foot pain. Clinical diagnosis of the painful os peroneum syndrome can be facilitated by the single stance heel rise and varus inversion stress test as well as by resisted plantarflexion of the first ray, which can localize tenderness along the distal course of the peroneus longus tendon at the cuboid tunnel. Radiographic diagnosis should include an oblique radiograph of the foot for visualization of the os peroneum and, if indicated, other imaging studies. Recommended treatment ranges from conservative cast immobilization to surgical approaches including: (1) excision of the os peroneum and repair of the peroneus longus tendon, and (2) excision of the os peroneum and degenerated peroneus longus tendon with tenodesis of the remaining remnant of peroneus longus to the peroneus brevis tendon.

The coracoid impingement syndrome

Coracoid impingement results from encroachment on the coracohumeral space, presenting as anterior shoulder pain and clicking, particularly in forward flexion, medial rotation, and adduction. In eight shoulders in seven patients, coracohumeral decompression by excision of the lateral 1.5 cm of the coracoid with re-attachment of the conjoined tendon gave pain relief in all, and complete relief in six. This procedure is described and recommended.

Stress fractures in 51 runners.

A prospective study was initiated in 1976 to investigate runners who are at risk for incurring stress fractures and how these fractures can be prevented. Fifty-one runners incurred 57 stress fractures. Tibial fractures were most common (25), followed by fibula (12) and metatarsal (8). Seven runners had previously sustained stress fractures, and six developed two stress fractures simultaneously. Five women over 30 years old had pelvic stress fractures. Stress fracture development was positively correlated with the presence of pes planus, weekly training distances greater than 20 miles, hard training surfaces, and training regimen modifications. The incidence did not correlate with generalized musculoskeletal laxity or tightness. Forty-four of 51 patients had initially positive roentgenograms. Five of five bone scans were positive. The average duration of rest before running was resumed was 7.4 weeks.

The roentgenographic evaluation of anterior shoulder instability.

Retrospective evaluations of roentgenograms of 83 patients with unilateral shoulder instability were surveyed to evaluate the usefulness of various radiographic projections and to correlate the information with the osseous pathology associated with prior glenohumeral dislocation. The Hill-Sachs and the osseous Bankart defects were considered pathognomonic radiographic signs of glenohumeral joint instability. Based on history, physical examination, and examination under general anesthesia, patients were divided into three categories--(1) dislocation group, (2) subluxation group, and (3) combination group. Roentgen projections evaluated included the anteroposterior view with the humerus in internal and external rotation, axillary view, West Point view, Stryker notch, and Didiee view. The Hill-Sachs defect on the posterolateral aspect of the humeral head was best demonstrated on the combination of an internal rotation and a Stryker notch view. The osseous Bankart defect on the anteroinferior glenoid rim was best documented on the Didiee and West Point views. The external rotation and axillary view did not add significantly to the preoperative radiographic findings. In a patient with an unstable shoulder, a radiographic series that includes an internal rotation, a Stryker notch view, and either a West Point or a Didiee view would maximize the diagnostic yield per radiographic cost, time, and exposure.

Risedronate in children with osteogenesis imperfecta: a randomised, double-blind, placebo-controlled trial

BACKGROUND Children with osteogenesis imperfecta are often treated with intravenous bisphosphonates. We aimed to assess the safety and efficacy of risedronate, an orally administered third-generation bisphosphonate, in children with the disease. METHODS In this multicentre, randomised, parallel, double-blind, placebo-controlled trial, children aged 4-15 years with osteogenesis imperfecta and increased fracture risk were randomly assigned by telephone randomisation system in a 2:1 ratio to receive either daily risedronate (2·5 or 5 mg) or placebo for 1 year. Study treatment was masked from patients, investigators, and study centre personnel. Thereafter, all children received risedronate for 2 additional years in an open-label extension. The primary efficacy endpoint was percentage change in lumbar spine areal bone mineral density (BMD) at 1 year. The primary efficacy analysis was done by ANCOVA, with treatment, age group, and pooled centre as fixed effects, and baseline as covariate. Analyses were based on the intention-to-treat population, which included all patients who were randomly assigned and took at least one dose of assigned study treatment. The trial is registered with ClinicalTrials.gov, number NCT00106028. FINDINGS Of 147 patients, 97 were randomly assigned to the risedronate group and 50 to the placebo group. Three patients from the risedronate group and one from the placebo group did not receive study treatment, leaving 94 and 49 in the intention-to-treat population, respectively. The mean increase in lumbar spine areal BMD after 1 year was 16·3% in the risedronate group and 7·6% in the placebo group (difference 8·7%, 95% CI 5·7-11·7; p<0·0001). After 1 year, clinical fractures had occurred in 29 (31%) of 94 patients in the risedronate group and 24 (49%) of 49 patients in the placebo group (p=0·0446). During years 2 and 3 (open-label phase), clinical fractures were reported in 46 (53%) of 87 patients in the group that had received risedronate since the start of the study, and 32 (65%) of 49 patients in the group that had been given placebo during the first year. Adverse event profiles were otherwise similar between the two groups, including frequencies of reported upper-gastrointestinal and selected musculoskeletal adverse events. INTERPRETATION Oral risedronate increased areal BMD and reduced the risk of first and recurrent clinical fractures in children with osteogenesis imperfecta, and the drug was generally well tolerated. Risedronate should be regarded as a treatment option for children with osteogenesis imperfecta. FUNDING Alliance for Better Bone Health (Warner Chilcott and Sanofi).