Jaakko Puranen

Outcome and prognostic factors of achilles rupture repair using a new scoring method.

A new clinical scoring system, including subjective assessment of symptoms and evaluation of ankle range of motion and isokinetic measurement of ankle plantar flexion and dorsiflexion strengths, is presented in 101 patients (86 men, 15 women) who had repair of a closed Achilles tendon rupture. Twenty-one patients were competitive athletes and 70 were recreational athletes. Eighty-one percent of the ruptures were related to sports, and 32% occurred while playing volleyball. Twenty-six patients had previous Achilles tendon symptoms. At followup, an average of 3.1 years after repair, the overall result scores were excellent in 34 cases, good in 46, fair in 17, and poor in four. Only age was a predictor of overall results. The isokinetic strength scores were excellent or good in 72 cases, fair in 18, and poor in 11. Presence of systemic diseases, activity level, previous Achilles tendon symptoms, and later return to physical exercise were predictors of strength results. Gender, body weight, height, period between rupture and operation, surgeon, rupture site, operative method, complications, and thickness, width, and area of the Achilles tendon at followup were not related significantly to the outcome.

Stress fractures caused by physical exercise.

A series of 142 stress fractures caused by sporting activities and physical exercise is presented. 121 fractures occurred in athletes and 21 in non-competitive sportsmen. Distance runners presented with 68 fractures, skiers 12, sprinters 10, orienteering runners 9, vaulters 3, and football-players 3 fractures. Athletes engaged in other events had fewer stress fractures. 76 fractures occurred in the tibia, 26 in the metatarsal bones, 20 in the fibula, 5 in the femoral neck, 4 in the femoral shaft, and 2 in the metacapal bones, lower pubic arch and sesamoid bones of the first MTP-joint. There was one fracture of each of the following: the humeral shaft, the ulna, the vertebral arch of L 5, the tarsal navicular and the proximal phalanx of the fifth toe. The treatment was generally a pause in training for 4-6 weeks, on the average. Running caused most of the stress fractures; the rest followed jumping exercises. The athletes mostly developed stress fractures during a period of alteration from one training session to another or during the preparation period close to the competition season. Joggers usually developped stress fractures 2-4 months after the beginning of regular training.

Symptoms and signs of sciatica and their relation to the localization of the lumbar disc herniation.

Neurologic symptoms and signs in patients with sciatica were prospectively studied and compared with myelographic and operative findings in 403 cases with lumbar disc herniation as the cause of sciatica with special reference to accuracy of the clinical level diagnosis. Fifty-six percent of the herniations at L4–5. However, pain projection into the first sacral distribution was most common. Neurologic symptoms and signs of involvement of a single root were present in 239 cases and of two roots in 154 cases in L4–5 and L5S1 herniations. Pain projection into the fifth lumbar distribution was a very important symptom for Identification of clinical findings of the fifth lumbar root involvement gave a level diagnostic accuracy comparable with myelography, while pain projection into the first sacral distribution was less reliable especially in cases with signs of two roots. The neurologic picture of high herniations was completely unreliable. Lumbar myelography or computer tomography is recommended as a routine preoperatlve study.

Arthrodesis of the knee with intramedullary nail fixation.

Thirty-three patients had an arthrodesis of the knee by means of an intramedullary nail introduced through the greater trochanter. Fifteen of the procedures were done for a failed knee arthroplasty; eight had failed because of infection and seven, because of aseptic loosening. Twenty-nine of the thirty-three knees united three to four months after the first attempt at arthrodesis and three united after technical errors were corrected. One knee had a broken nail and a non-union; this was still untreated at the time of writing. Four nails broke: three in the line of fusion and one in the line of an infected supracondylar pseudarthrosis of the femur. No new infections developed after the arthrodesis. Three patients had had an infection and a chronic fistula before the arthrodesis, and the fistulae healed six, fourteen, and eighteen months postoperatively. In another patient, who had had infection and necrosis of the skin preoperatively, the wound healed in six months. All of these knees healed without an additional major operation. The functional result was satisfactory in all patients. After the arthrodesis, seventeen of the thirty-three patients needed less aid when walking, and no patient needed more aid. Fusion of the knee with a long intramedullary nail can be safe and effective, even in the presence of infection, if the revision is performed properly and certain technical principles are followed. It is especially important to establish good contact between the resected bones.

Arthrography, clinical examination, and stress radiograph in the diagnosis of acute injury to the lateral ligaments of the ankle

We examined 188 consecutive patients, each of whom had an acute ankle sprain, using clinical stability as sessment, stress radiographs, and arthrography to compare the reliability of these methods used in diag nosing lateral ligament ruptures of the ankle. Sixty-six of the ankles were treated operatively. Arthrography accurately detected ligament damage in all of the pa tients with this injury and revealed the extent of the injury in about 85%, whereas clinical examination and stress radiographs detected only about half of the injuries. The injuries and the results of these two meth ods were often controversial, as our study will show.

Postoperative intervertebral discitis

Discitis is a rare complication of disc operation. During a 10-year-period 1100 patients were operated for lumbar disc herniation and only eight patients developed postoperative discitis. The symptoms began 3 weeks after the operation and the most prominent clinical feature was back pain with muscle spasm. The sedimentation rate was highly elevated but the body temperature was slightly elevated for only a few days. Typical radiographic findings were narrowing of the affected disc space and end-plate resorption 3-4 weeks after the initial symptoms. In the early phase, CT showed hypodense disc material in the affected disc space, which may be the first radiological sign of discitis.

Surgical Treatment of Overuse Injuries to the Achilles Tendon

AbstractA clinical survey was made of 275 consecutive overuse injuries of the Achilles tendon in 228 patients (170 men; 58 women) operated on during the period 1980–1989 at the Clinic of Sports Medicine, Deaconess Institute of Oulu, Finland, (prospective material) and at the Department of Surgery of Oulu University Central Hospital (retrospective material); 60% of patients lived in Northern Finland, 22% elsewhere in Finland, and 18% abroad. Their mean age was 32 years, and 11.8% were athletes at the international level, 28.5% at the national level, and 19.7% at a district level; 39.5% were recreational athletes. There were more long- and middle-distance runners, joggers, and orienteers than other athletes. All the patients had undergone combinations of different modes of conservative treatment. The results of the operative treatment were excellent or good in 73.4% of cases, fair in 78.5%, and poor in 8.0%. There were 34 complications, of which 29 were wound complications; eight of these were treated surgically with good results. Thirty reoperations were needed by 22 patients because of recurrence of pain or operative failure. The total results including those of reoperations, were excellent or good in 219 cases (79.7%), fair in 54 (19.6%), and poor in 2 (0.7%).

Arthrography in the Diagnosis of Ligament Injuries and Classification of Ankle Injuries

Arthrography was assessed in 300 cases of ankle injury to determine its diagnostic information yield and its aid in classifying ankle injuries. No complications occurred as a result of the procedure. In 59 cases, information gained from the procedure was verified at surgery. Arthrography was considered to give valuable information in 85% of the cases of ligament ruptures.

The Clinical Significance of Osteomedullography in Fractures of the Tibial Shaft

Osteomedullography with phlebopression of the extraosseous softtissue veins is a reliable technique in evaluating the repair process in fractures of the tibial shaft in which usual clinical and roentgenographic criteria might prove inadequate. In normally healing fractures, intraosseous flow of contrast medium crossing the fracture gap was seen within ten weeks after injury at the latest. This fact can be used in diagnosing delayed union as well as in determining whether bone-grafting is necessary. There is no need to operate on the fracture if it will consolidate in some months without surgery. Osteomedullographic examinations establish the importance of intramedullary vascular connections in the healing of fractures.

DISTURBED PATTERNS OF VENOUS DRAINAGE OF THE FEMORAL NECK IN PERTHES' DISEASE

1. Intra-osseous venographs have been obtained in twenty-eight hips affected by Perthes disease and in twenty normal hips after the injection of opaque medium into the femoral neck. 2. In the normal hips the contrast medium drained rapidly into the local veins; none flowed distally into the diaphysis. 3. In the initial and in the fragmentation stages of Perthes9 disease some contrast medium always flowed into the diaphysis and the flow into the local veins was greatly reduced. 4. In the restitution stage the venographs approached normal. 5. The implications of these findings are discussed.