Martin E. Blazina

The modified Bristow procedure for recurrent dislocation of the shoulder

A review of fifty-one cases of the modified Bristow procedure for recurrent anterior shoulder instability is presented. The results were favorable. The redislocation rate was 2% with few complications. The average limitation of motion was 11 degrees of external rotation. Athletic individuals with involvement of the dominant shoulder were not capable of returning to high performance levels of overhead sports activity (particularly throwing) after the operation.

Degeneration and Rupture of the Achilles Tendon

An analysis was perfomed on 32 operative cases of Achilles tendon disease. Two patient classifications emerged. One group suffering an acute rupture of the Achilles tendon with no antecedent complaints, and the second group had a history of chronic pain, weakness and functional loss. This latter group could be further differentiated by the occurrence of tendon failure in 10 of 22 cases. Surgical exploration in the group with chronic complaints demonstrated a high incidence of diffuse reactive changes such as fibrinoid and myxomatous degeneration, fibroisis and metaplastic calcification. Degenerative disease of the Achilles tendon should be recognized and treated not as a simple injury but as a pathological lesion.

Fatigue Fracture of the Tarsal Navicular

Fatigue fracture of the tarsal navicular is an uncommon and unusual vertical type of fracture which may require special roentgenographic views and laminagraphy for detection. This type of fracture has not been previously reported in man. Two cases of fatigue fracture of the tarsal navicular in male high-school athletes have been presented. One of these fractures healed with plaster-cast immobilization and the other was treated by open reduction and internal fixation.

Ligament replacement with an absorbable copolymer carbon fiber scaffold--early clinical experience.

Eighty-two patients, average age 29 years, were surgically treated (during the period from April 1981 to July 1983) for both acute (8%) and chronic (92%) knee ligament instabilities. An absorbable copolymer-carbon fiber ligament prosthesis was used as a tissue scaffold. Seventy-five percent had anterior cruciate ligament reconstructions, 6% had anterior cruciate and posterior cruciate ligament reconstructions, 6% had just posterior cruciate ligament reconstructions, and 9% had other combinations of anterior cruciate ligament, medical collateral ligament, and lateral collateral ligament reconstructions. Preoperative and postoperative evaluation, consisting of questionnaires, physical examinations, and isoskinetic testing, revealed significant improvements in categories of stability, pain, function, and strength persisting to the end of the study at 24 months. Arthroscopic examination and histologic studies of retrieved specimens demonstrated well-vascularized reconstructions with collagenous tissue ingrowth into the carbon-copolymer implants.

The results of operative treatment of osteochondritis dissecans of the patella

The course of osteochondritis dissecans (OCD) of the patella and the results of operative treatment are ana lyzed retrospectively in a review of 31 operatively treated cases in 25 patients. Followup was obtained for 21 cases, with an average of 73 months (range, 15 months to 20 years). These 25 patients were predom inantly males, and averaged 18 years of age at the time of surgery. A history of trauma was associated with the lesion in 38% of the cases, and the lesion was bilateral in one out of four patients. The most common present ing complaints were subpatellar pain and swelling. The most common initial physical findings were patellofem oral crepitus and joint effusion. Forty-four operations were performed on 31 knees. The most commonly performed procedures were cu rettage of the patella and removal of loose bodies, in combination or as part of another procedure. A new patellofemoral rating scale was used to evaluate re sults. Thirty-eight percent of the knees had a good or excellent result, while 62% had a fair or poor result. Persistent pain with restricted function and residual patellofemoral crepitus were common findings. In general, the patients who come to surgery for OCD of the patella have a guarded prognosis for full recovery of knee function.

Multiphasic view of medial meniscectomy

In a retrospective study, the records of a group of 816 patients who had tears of the medial meniscus alone were selected for review from a total of 6,000 records of patients who had had knee surgery (1966 to 1976). According to the operative reports, these 816 patients had no other structural or pathologic findings at the time of medial meniscectomy. In an average of 2.0 years after initial surgery to the knee, 210 patients required subse quent surgical procedures for progressive meniscal pathology (38), articular cartilage damage (64), or ligamentous instability (108). The recognition of the possibility for future surgery after medial meniscectomy is an important finding which must be acknowledged by the treating physician and to the patient. The evidence from this review suggests that others should review series of patients with tears of the medial meniscus and should attempt to gain understanding of the basic pathologic pro cesses.

The use of electrosurgery for arthroscopic subcutaneous lateral release.

49 patients underwent subcutaneous lateral retinacular release for pa tell of emo ral malalignment syndromes by a new technique utilizing the arthroscope and electrocautery. In this technique, the tight lateral patellofemoral ligament and lateral retinaculum are transected with the electrocautery under direct arthroscopic visualization. It is possible to directly observe the progress and completeness of the release, and to cauterize any bleeding vessels sequentially as they are transected. The procedure is simple, quick, and has a low 3.8% rate of complication. In the postoperative period pain is minimal, requiring only non-narcotic medication. Patient hospital stay is reduced, with dismissal usually one day after surgery. Knee motion as well as quadriceps control are rapidly recovered. One week after surgery 90% of patients gained 90° or more of flexion, and the remaining patients achieved this by the second week after surgery.

Iliotibial band transfer for anterolateral rotatory instability of the knee. Summary of 54 cases.

Forty-eight patients who underwent distal iliotibial band trans fer (Ellison) for anterolateral rotatory instability and who were over 1 year postsurgery presented for examination and an additional six patients completed a written subjective evalua tion. Five patients only had isolated lateral surgery. In 33 patients there was an additional diagnosis of anteromedial rotatory instability. Of the patients 44% had had no previous surgery, while 36% had undergone one procedure and 19% had undergone more than one procedure. In combination with iliotibial band transfer, 74% had a lateral meniscectomy, 44% had a capsular reefing, 38% had a medial meniscectomy, 44% had a pes anserinus transfer, and 8 patients had prosthetic cruciate ligament replacement. In these eight patients, five prosthetic ligaments had fractured and were included but three were intact and were excluded. Thirty-four percent of the patients were initially injured in football. All patients had thorough knee and radiographic examinations; strength mea surements by using the Cybex testing for knee extension; flexion and external rotation; and completed a subjective ques tionnaire. Of the patients 87% responded that they were im proved and thought the surgery was worthwhile. Ninety-one percent had positive jerk tests preoperatively but only 46% were positive at followup. However, while 53% reported no episodes of giving way, 28% reported monthly episodes, 9% weekly episodes, and 8% daily episodes. Only 15% had no difficulty cutting while 55% had some and 26% had extreme difficulty or were unable to do so. Only 23% reported no difficulty with jumping, but 48% had some difficulty, and 30% were unable to jump and had extreme difficulty jumping. Only 28% of patients had returned to their desired level of activity while 46% had reached only 50% of their desired level. Only 13% expressed complete confidence in the knee while 21 (46%) were in the 75 to 90% confidence range, while 22% had less than 50% confidence. Of the patients 29% had lost extension and 57% had lost flexion. Ninety-one percent had increased varus (adduction) instability at followup, but this did not appear to have clinical significance. On follow-up x-ray films 70% had osteophyte formation, 65% had joint space narrowing, 46% had pain requiring aspirin. Eighty percent had atrophy averaging 1.72 cm. Thirty percent had tenderness at Gerdys tubercle. As in all studies involving the knee ligaments, the many variables are dependent and poor results do not reflect failure of this one part of treatment. No patient was made worse by the procedure; there appears to be defmite reduction in anterolateral rotatory instability after iliotibial band transfer, which was maintained for more than 1 year after surgery.

Incidental metastatic mammary carcinoma in a total knee arthroplasty patient.

Incidental metastatic breast carcinoma was discovered by histologic examination in a total knee arthroplasty (TKA) patient. A 70-year-old woman was evaluated for increasing debilitating pain in the right knee. A radiograph demonstrated only degenerative changes. Degenerative changes were noted in the gross and microscopic examination of the knee specimen. The unsuspected focus of poorly differentiated adenocarcinoma was suggestive of mammary carcinoma. A mass in the right breast then was subsequently noted on reexamination. Mastectomy showed infiltrating adenocarcinoma with metastases to axillary lymph nodes, and diffuse involvement of the skeleton was demonstrated with a bone scan. This case emphasizes the importance of a meticulous history and a complete medical examination before surgery, detailed examinations of the excised knee and joint fragments by a pathologist after a TKA operation. Malignancy can be missed with only gross specimen evaluations and radiographs.

The synovial response after CO2 laser arthroscopy of the knee

The CO2 laser is a precision surgical laser because of its high degree of absorption in soft tissue with limited lateral damage. The tissue, which absorbs the CO2 laser energy, and has a high water content, will be converted to vapor with a small residue of ash and a by-product of heat. The laser can only be effective if these by-products, i.e. vapors, heat, and carbon ash residue, are not injurious and are well tolerated by the joint. These by-products must be either reabsorbed by the synovium or remain as a nonviable substance in the joint. From April 1989 through April 1990, 40 patients underwent 43 operative arthroscopies of the knee using the Pfizer CO2 laser. All procedures were chondroplasties, synovectomies, and/or meniscectomies. All accessible CO2 carbon ash residue was removed from the joint after the procedures using an intraarticular shaver and hand rasp. Postoperatively there were no cases of hemorrhagic effusions, subcutaneous emphysema, or synovitis. Histologic examinations performed on 10 patients undergoing subsequent surgery showed no evidence of carbon ash residue or synovitis seen grossly or microscopically. The carbon ash residue is not noxious to the joint and is completely removed from the joint, presumably by the synovial response.