Arthroscopic treatment of soft-tissue impingement of the ankle in athletes

Sixty ankle arthroscopies were performed on patients with chronic soft-tissue impingement of the ankle after an ankle sprain between January 1989 and January 1994. Preoperative examination findings featured tenderness localized to the anterolateral aspect of the ankle, no instability, and, with the exception of 2 patients, normal radiographs. A preoperative bone scan was performed on 34 patients and was positive in each case but was not specific. Arthroscopy was performed an average of 23 months after injury. Results were determined by using a new ankle rating score. Hypertrophic synovium, synovitis, or fibrous adhesions were arthroscopically visualized and resected in all cases. The average follow-up was 27 months (range, 6 to 64 months). Thirty-one patients underwent complete evaluation and 29 were evaluated over the telephone. There were 51 excellent, 7 good, 1 fair, and 1 poor results. The diagnosis of chronic soft-tissue impingement of the ankle can be made from an appropriate history, thorough physical examination, and plain radiographs. Ankle arthroscopy with resection of impinging hypertrophic synovium or fibrous bands occurring after an ankle sprain was effective in alleviating pain in athletes.     

Arthroscopic treatment of anterior ankle impingement

Ankle arthroscopy has recently allowed the elaboration of less invasive techniques for the treatment of anterior impingement. Its indications, advantages, and drawbacks in this application are discussed. Between 1987 and 1994, 133 patients were treated for ankle impingement. Among them, 58 patients, 37 men and 21 women (mean age, 28.5 years), who had failed a trial of conservative treatment were treated by means of tibiotalar arthroscopy. Twenty-seven were athletes engaged in sports with abnormal stressing of the ankle. According to McDermott's radiological classification, there were 15 stage I cases, 23 stage II, 13 stage III, and 7 stage IV. Preoperative evaluation with a modified version of McGuire's scoring system gave 50 cases rated as "poor" (< 60 points) and 8 cases rated as "fair" (60-67 points). Treatment consisted of removal of adhesions, cartilage shaving, and removal of the bone impingement with powered instruments, curettes, or small osteotomes. Follow-up was from 8 to 62 months (mean, 21.5 months). The postoperative McGuire ratings were 37 good, 13 fair, and 8 poor. There were no major complications. Recurrence of impingement was observed in four cases of stage III and IV. The conclusion is drawn that ankle arthroscopy is a sound method for the treatment of anterior impingement. Even in cases with severe joint cartilage impairment, it plays a therapeutic role as a means of postponing a possible arthrodesis.     

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.     

Arthroscopy for problems after ankle fracture

From 1990 to 1994 we undertook arthroscopy of the ankle on 34 consecutive patients with residual complaints following fracture. Two groups were compared prospectively. Group I comprised 18 patients with complaints which could be attributed clinically to anterior bony or soft-tissue impingement. In group II the complaints of the 16 patients were more diffuse and despite extensive investigation the definitive diagnosis was not clear before arthroscopy. At the time of the fracture, some osteophytes were already present in 41% of the patients. These were related to previous supination trauma and participation in soccer. Arthroscopic treatment consisted of removal of the anteriorly located osteophytes and/or scar tissue. After two years, group I showed a significantly better score for patient satisfaction (p = 0.02). There were good or excellent results in group I in 76% and group II in 43%. Patients with residual complaints after an ankle fracture and clinical signs of anterior impingement may benefit from arthroscopic surgery. The place for diagnostic ankle arthroscopy is limited.     

Apparent feeding behaviour of ensheathed third-stage infective larvae of human hookworms

We examined 16 feet, 33 to 133 months (mean 83) after simultaneous calcaneocuboid and talonavicular fusions performed for a variety of painful disorders of the hindfoot. Objectively, four feet were rated excellent, eight good, four fair and none poor. There was one asymptomatic nonunion of the talonavicular joint. Progressive degenerative arthritis of the ankle was seen in six patients and of the naviculocuneiform joint in seven. Biomechanically, simultaneous calcaneocuboid and talonavicular arthrodesis is better than an isolated talonavicular fusion and is a simple and effective alternative to triple arthrodesis.     

Intraarticular dexamethasone in advanced chronic synovitis in hemophilia

From 1988 to 1966, 34 patients with advanced chronic hemophilic synovitis (25 Grade III and nine Grade IV) were treated with intraarticular injections of long acting dexamethasone (sodium phosphate of dexamethasone plus acetate of dexamethasone) in cycles of three injections with 3-week intervals between each injection with 6-month rest intervals between cycles for as many as three cycles, depending on the evolution of each case. All patients had chronic severe synovitis, axial deformity, muscular atrophy, and diminution of range of movement. There were 31 knees, two ankles, and two shoulders. Subjective and objective evaluations were done grouping the results in good, fair, and poor according to grade of patient satisfaction, presence of synovitis and pain, range of movement, and limitation of activities of daily living. In the subjective results there were 19 good results, 12 fair results, and four poor results, and in the objective evaluation there were 22 good results, nine fair results, and four poor results at an average followup of 1.5 years. The use of intraarticular dexamethasone as an alternative in the short to medium term for treatment of advanced chronic hemophilic synovitis with pain and limitation of function before doing an invasive surgical treatment is proposed.     

Metabolism of 2,4-dichlorophenoxyacetic acid. IX. Gas-liquid chromatography of methyl esters of amino acid conjugates

Cyclophosphamide, an immunosuppressive agent, was administered as an additional mode of therapy to 30 patients with idiopathic thrombocytopenic purpura (ITP) refractory to conventional management. Of 22 previously tested by splenectomy an excellent response was achieved in 12, who remained in complete hematologic remission for 14-96 months after therapy was discontinued; a fair response in 3, with definite increase in platelets, but not to normal levels; and a poor response in 7 who failed to improve. Of 8 nonsplenectomized patients who failed to respond to steroids or maintain a response after steroids were discontinued, 4 were considered excellent, 1 required continued therapy to remain in remission (good response), 2 were fair, and 1 was poor. Remission was observed in 2-10 weeks in both groups and appeared to be related to duration of disease; presence of disease for less than 1 year was associated with a much better response to treatment (11 of 15) when compared with disorders lasting over 2 years (6 of 15). Cyclophosphamide therapy offers additional means of treating patients with ITP who fail to respond to conventional therapy and may serve as an alternative to splenectomy when surgery is contraindicated.     

The Mitchell procedure for the treatment of adolescent hallux valgus. A long-term study

Thirty patients who had had a total of fifty-one Mitchell procedures to correct adolescent hallux valgus deformities were examined clinically and radiographically an average of seven years (range, three to seventeen years) after the operation. The average age of the patients at the time of the operation was fifteen years (range, ten to nineteen years). The result was excellent in nineteen feet, good in sixteen, fair in six, and poor in ten. The fair and poor results were associated with recurrence of the deformity, stiffness (real or perceived), and unsightly scars. The cause of the fair and poor results was inadequate correction at the time of the operation in six feet and loss of fixation in two; the loss of fixation resulted in one recurrence and one malunion. The remaining eight patients who had a fair or poor result were not totally satisfied and had reservations about more than one of three categories (relief of discomfort, appearance, or range of motion). Seventeen feet had a plantar callosity beneath the second metatarsal head, suggesting increased load-bearing by the second metatarsal. Although sixteen callosities caused no symptoms at the most recent follow-up evaluation, the long-term implications of this altered pattern of weight-bearing are unknown.     

Treatment outcome with radiation therapy after breast augmentation or reconstruction in patients with primary breast carcinoma

BACKGROUND: Analyses were performed to determine local control and cosmetic outcome of breast carcinoma patients with prosthetically augmented or reconstructed breasts who had received radiation therapy (RT). METHODS: Twenty-one newly diagnosed breast carcinoma patients with prosthetically augmented or reconstructed breasts were treated with external beam RT. All patients received whole breast RT (median dose, 50.4 gray [Gy]) and 19 were boosted to a median dose of 60.4 Gy. A median dose of 50.4 Gy was delivered to the regional lymph nodes in 12 patients. Tissue equivalent bolus material was used in six patients. Seventeen patients received adjuvant systemic therapy. Cosmetic results were evaluated at 3-6-month intervals. RESULTS: With a median follow-up of 32 months, good/excellent cosmetic results were observed in 71% of patients (100% in those with augmented breasts and 54% in those with reconstructed breasts). Four patients (19%) with fair/poor cosmetic outcomes required implant removal and/or revision. Multiple clinical and treatment-related factors were analyzed for their impact on cosmetic outcome. A worsened cosmetic result was observed with increasing stage (P = 0.076), breast reconstruction (vs. augmentation) (P = 0.030), and bolus application (P = 0.016). All patients with fair/poor cosmetic outcomes had time intervals from implant insertion to RT ranging from 53-213 days. Two patients developed an isolated local recurrence within the augmented breast. CONCLUSIONS: Patients with prosthetically augmented breasts can undergo RT and expect good/excellent cosmetic results. Patients with reconstructed breasts are at a significantly greater risk for cosmetic failure. This risk may be related to the higher percentage of patients with advanced disease, those who received bolus application, and those who received earlier delivery of RT (after the cosmetic procedure) in reconstructed breasts.     

Urinary flow rates in hypospadias

OBJECTIVES: To determine long-term results of patients who underwent primary ligament repair and delayed reconstruction for lateral ligament instability. DESIGN: Retrospective. SETTING: Outpatient clinic. PATIENTS/PARTICIPANTS: Patients who had undergone acute repair or delayed reconstruction at this institution between 1958 and 1977, excluding patients who were deceased or who could not be located. INTERVENTION: Forty-eight patients (fifty-three ankles) underwent twenty-two primary ligament repairs and thirty-one delayed reconstruction operations. MAIN OUTCOME MEASUREMENTS: Clinical results graded with clinical scale and radiologic results based on stress radiographs and plain film radiographs. RESULTS: At an average of twenty years after operation (range 12 to 33 years), patients were satisfied with forty-nine ankles, satisfied with reservations with two ankles, and dissatisfied with two ankles. Clinical results after repair were excellent in twenty ankles, good in one, fair in none, and poor in one. After reconstruction, the results were excellent in twenty-one ankles, good in six, fair in one, and poor in three. In the primary repair group, the mean talar tilt with stress testing improved from 20.7 +/- 10.7 degrees before operation to 2.8 +/- 3.0 degrees after operation. In the reconstruction group, the mean talar tilt improved from 20.7 +/- 8.4 degrees before operation to 2.8 +/- 3.5 degrees after operation. CONCLUSIONS: Clinical and radiologic results were similar in the repair and reconstruction groups. The majority of severe (Grade III) ankle sprains may be treated nonoperatively, but if residual instability occurs, late reconstruction should achieve satisfactory results.     

Defects of pars interarticularis in athletes: a protocol for nonoperative treatment

The purpose of this study was to report the results of a specific treatment protocol for athletes with spondylolysis or spondylolisthesis of the lumbar spine. A retrospective study with recent follow-up was performed on 82 patients treated with restriction of activity, bracing, and physical therapy. All of the patients were involved in sports at first onset of symptoms. Sixty-six patients were boys and 16 were girls. Activities involving repetitive hyperextension and/or extension rotation of the lumbar spine were described as painful in 98% of the patients. Of the 62 patients with spondylolysis, 53 (85%) had an L5 defect and nine (15%) an L4 defect (90% of these 62 patients' defects were located in the most caudad mobile vertebra). Thirty-seven patients had bilateral pars defects, and 25 had unilateral defects. Eight patients had normal roentgenograms, but these eight had abnormal bone scans. Nine patients with spondylolysis underwent posterolateral fusion. Average follow-up was 4.2 years. Fifty-two (84%) had excellent results, eight had good results, and two had fair results. Twenty patients had a spondylolisthesis: 12 were grade I, six were grade II, and two were grade III. Twelve patients (60%) required surgery; 9 had excellent results, one had good results, one had a fair result, and one had a poor result. Pars defects must be suspected in the differential of low back pain in young athletes. Oblique radiographs are frequently diagnostic; however, if the history and examination are suggestive despite normal plain films, a bone scan should be obtained. Nonoperative management of pars defects is frequently successful.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical results of the Mayo total ankle arthroplasty

Two hundred and four primary Mayo total ankle arthroplasties were performed in 179 patients at the Mayo Clinic from 1974 through 1988. We evaluated the clinical result after 160 arthroplasties in 143 patients who had been followed for two years or more (mean, nine years; range, two to seventeen years). The result was good for thirty-one ankles (19 per cent), fair for fifty-five (34 per cent), and poor for seventeen (11 per cent); fifty-seven arthroplasties (36 per cent) were considered to be a failure (defined as removal of the implant). Adequate preoperative and follow-up radiographs were available for 101 ankles (eighty-nine patients). There was radiographic evidence of loosening of eight tibial components (8 per cent) and fifty-eight talar components (57 per cent), but we found no association between the clinical and radiographic results. Complications occurred after nineteen (12 per cent) of the 160 arthroplasties, and ninety-four additional reoperations were necessary after sixty-six (41 per cent). On the basis of these findings, we do not recommend ankle arthroplasty with a constrained Mayo implant for rheumatoid arthritis or osteoarthrosis of the ankle.     

Changes in visual functions in myopia 6 months after photorefractive keratectomy

Clubfoot deformity associated with congenital constriction band syndrome (CCBS) has different characteristics than classic idiopathic clubfoot, and is more difficult to treat. We describe the manifestations, treatment, and outcomes of nine patients treated for 11 CCBS-associated clubfoot deformities between 1980 and 1993. All but one of these children had an abnormal gestational or neonatal history. From an assessment of the correctability of the deformity and the associated secondary changes, the clubfoot severities were all classified as grade B (intermediate). The constriction bands in eight clubfeet were classified as type 0 (5 feet), II (2), or III (1), according to the location and depth of the band. Band types in three feet were unclassified because the band release was performed at other hospitals. We released the bands before correcting the clubfeet in the two patients with type II bands. The five patients with type 0 bands received casting first but with poor response. All clubfeet were corrected surgically; the procedures were posteromedial release in 10 feet, split tibialis anterior tendon transfer in five, and lengthening of the Achilles tendon in three. At an average follow-up of 3.8 years, seven of the 11 clubfeet were classified as having good results and four as fair. Among the six clubfeet with constriction bands on the ipsilateral leg, five were classified as having good results and one as fair. Two of the five clubfeet without constriction bands on the ipsilateral leg had good results and three had fair results. The presence of a band did not influence the final outcome of the clubfoot deformity (p > 0.05). In the five patients with forefoot varus deformity due to peroneal weakness, tibialis anterior tendon transfer successfully corrected the deformity. All the clubfeet treated in this series were plantigrade after treatment and had satisfactory results.     

Displaced intra-articular fractures of the calcaneus treated non-operatively. Clinical results and analysis of motion and ground-reaction and temporal forces

Twenty-seven patients who had a unilateral displaced intra-articular fracture of the calcaneus were managed with a cast instead of with reduction or an operation. The clinical result after a mean of six years (range, two to ten years) was excellent in five patients, good in five, fair in seven, and poor in ten. The sixteen patients who were re-examined for this study and for whom the gait was analyzed demonstrated abnormalities in ground-reaction force with regard to vertical force (F3) and temporal force factors (T2, T3, T6, and T9). Analysis of temporal and distance factors showed a trend toward a decreased proportion of single-limb support on the involved side. Three-dimensional motion analysis of the ankle and hindfoot was performed with electrogoniometers as the subject walked on a level surface, on a 10-degree side-slope, and up and down stairs. Motion was decreased in the sagittal, coronal, and transverse planes during walking on level ground and on a side-sloping surface. Significant decreases in motion in these planes were also seen during walking up and down stairs. Although these patients did not have a subsequent reconstructive operation, most had a residual functional deficit.     

Autologous breast reconstruction after breast-conserving cancer surgery

Breast-conserving therapy, which aims to reduce trauma by preserving as much of a patient's natural appearance as possible, does not necessarily lead to an optimal cosmesis. We hypothesized that combining plastic and oncologic surgeries would greatly reduce the physical and psychological traumas and produce an optimal cosmesis without impairing the oncologic outcome. We performed breast reconstruction on 40 cancer patients. Of those 40 patients, 15 received combined plastic and oncologic surgeries. Procedures depended on breast size: mammareduction plasty in cases with sufficient volume, and reconstruction using myocutaneous latissimus dorsi flaps for those with less volume. Cosmetic results were rated good to poor. Of the 15 primary reconstruction patients, 86.7 percent of the cases showed good results and 13.3 percent fair; in the secondary cases, 68 percent were good, 16 percent fair, and 16 percent poor. Through a follow-up and cosmetic evaluations by both surgeons and patients, the study showed that combining aesthetic improvements and oncologic surgery does not compromise patient safety, reduces mental and physical trauma, and frequently results in superior cosmesis, thereby improving the patient's overall health.     

Total knee arthroplasty in patients receiving Workers' Compensation

The poor outcomes in patients who have a low-back injury that was sustained while they were on the job have been well described in many studies. The purpose of the current study was to determine the influence of Workers' Compensation on the outcome of total knee arthroplasty in forty-two patients who had been managed between January 1980 and December 1993. There were thirty-two men and ten women, and the mean age at the time of the operation was forty-eight years (range, twenty-nine to sixty-eight years). These patients were directly matched with a group of forty-two patients who were not receiving compensation. The two groups were matched with regard to nine parameters: age, gender, obesity index, preoperative deformity in the coronal plane, preoperative level of symptoms, preoperative radiographic severity according to the criteria of Ahlb?ck, method of fixation, number of previous procedures, and duration of follow-up. After a mean duration of follow-up of eighty months (range, forty-eight to 178 months), the patients who were receiving compensation had a mean Knee Society score of 64 points (range, 25 to 100 points). Twelve (29 per cent) of the patients in this group had an excellent or good clinical result, and thirty (71 per cent) had a fair or poor result or had had a revision. The patients who were not receiving compensation had a mean Knee Society score of 93 points (range, 57 to 100 points) after a similar duration of follow-up. Thirty-seven patients (88 per cent) in this group had an excellent or good clinical result, and five (12 per cent) had a fair or poor result or had had a revision; the difference between the two groups with regard to fair or poor results and revisions was significant (p < 0.01). With the numbers available, no significant differences could be detected between the two groups with regard to objective measurements of range of motion and stability or with regard to radiographic alignment, the presence of radiolucent lines, or the shedding of beads. On the basis of our findings, we believe that surgeons should be aware that Workers' Compensation is one of several variables that may have an untoward influence on the perceived outcome of total knee arthroplasty.     

Predictors of outcome in patients with chronic back pain and low-grade spondylolisthesis

STUDY DESIGN: Retrospective case series. OBJECTIVES: To determine the factors influencing symptom relief after uninstrumented posterolateral spinal fusion with or without decompression in adult patients with chronic back pain and previously asymptomatic low-grade isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: The role of previously asymptomatic low-grade isthmic spondylolisthesis in chronic adult low back pain is unclear. Operative intervention in this setting is controversial. METHODS: Twenty-four consecutive adult patients with chronic low back pain and low-grade isthmic spondylolisthesis first detected during routine work-up of new onset low back pain underwent spinal fusion with or without decompression. The influence of active worker's compensation or litigation claims, radicular pain, concomitant laminectomy, age, gender, fusion to L4, intervertebral disc bulge, and pseudarthrosis were investigated. RESULTS: All 13 patients involved in worker's compensation claims or pending litigation had fair or poor results. Nine of 11 patients without such issues had good or excellent results. Although the strong association of worker's compensation with poor results made it difficult to assess the importance of other risk factors, the data suggest that good results may be more likely in patients with radiculopathy who undergo laminectomy. CONCLUSIONS: This investigation, although limited by a number of factors including small sample size and retrospective, unblinded review, suggests that active worker's compensation and litigation issues are associated strongly with poor results of operative management for chronic low back pain in adult patients with low-grade spondylolisthesis.     

Therapy of dislocated calcaneus joint fracture with the AO calcaneus plate

From August 1992 to March 1997, 66 patients with 71 displaced intraarticular calcaneal fractures were prospectively examined after an operative treatment using an extended lateral approach and the ASIF calcaneal plate followed by early functional postoperative treatment (mean follow-up 25 months, retrieval rate 96%). To classify the type of fracture and to verify the results of reduction and of retention CT scans in the coronal and transverse plane were performed pre- and postoperatively and on the day of assessment. The Zwipp Score was used for clinical evaluation. After fractures with 5 to 8 points according to the calcaneal fracture scale, 97% of the patients had an anatomical or near anatomical reduction of the posterior facet and the clinical outcome in 82% of the patients was graded as good or excellent. In 70% of patients with a fracture rated 9 to 10 points a good reduction was demonstrated and clinically there were 67% good or excellent results. But in the fractures with 11 to 12 points, despite 40% good reductions, the clinical outcome was graded as good in 10% of the patients only. However, if the post-operative displacement of the posterior facet was more than 2 mm no patient had a good result independent of the type of fracture. Due to restoration of the geometry of the most comminuted fracture types and the immediate partial weight bearing secondary soft tissue problems could be minimized without any loss of articular reduction. Anatomical reduction and stable internal fixation together with adequate physical therapy are apparently preconditions but not a guarantee for a good clinical result after displaced calcaneal fractures.     

Displaced fractures of the glenoid fossa. Results of open reduction and internal fixation

Displaced fractures of the glenoid fossa are an uncommon and anatomically diverse group of injuries. Failure to restore anatomy in these fractures results in poor outcome in most cases. The success of a treatment protocol that encompasses appropriate preoperative imaging, injury pattern assessment, prudent approach choice, and a comprehensive reduction and fixation tactic was evaluated. Twenty-seven patients were assessed clinically and radiographically at a mean followup interval of 43 months from surgery. Anatomic reconstruction was achieved in 24 (89%) patients. Three patients had residual joint incongruities measuring 2 mm or less. The only perioperative complication was a partial superficial wound dehiscence. Two additional patients had infraspinatus palsies of indeterminate origin. Functional rating revealed six (22%) excellent, 16 (60%) good, three (11%) fair, and two (7%) poor outcomes. The fair and poor outcomes largely were related to associated injuries. These findings show that anatomic surgical reconstruction with a low complication rate and good functional outcome can be obtained for most patients with glenoid fossa fractures.     

Surgical treatment of epilepsy in tuberous sclerosis: strategies and results in 18 patients

BACKGROUND: Seizures in patients with tuberous sclerosis complex (TSC) are often intractable to antiepileptic medications and searching investigation may provide evidence that surgical treatment can be considered. OBJECTIVE: To review the results of investigation and surgical therapy, a treatment modality not generally considered in patients with medically refractory seizures and TSC. METHODS: We report 18 patients (9 male) with TSC who underwent surgical treatment of medically refractory epilepsy. Twelve patients had a well-localized epileptogenic lesion and were treated by lesionectomy or focal resection. Resections were: 7 frontal, 4 temporal, 1 frontotemporal, 1 occipital, and 1 frontoparietal. Four patients underwent more than one operation. Six patients had corpus callosotomy (CC). RESULTS: Follow-up ranged from 1 month to 47 years. Outcome of the patients treated by resection was excellent in 7 (5 were seizure-free and 2 had auras only), good in 1, fair in 3, and 1 was lost to follow-up. Best outcome was obtained in patients who had focal seizures and good imaging and EEG correlation, although they might have multiple seizure types, other imaging abnormalities, and multifocal or generalized EEG findings. When there was no such correlation, CC was found to be an option as five patients had at least some improvement and only one showed no change. CONCLUSION: Surgical treatment of patients with TSC and intractable epilepsy is most effective when a single tuber or epileptogenic area can be identified as the source of seizures and resected. This may be possible even when other tubers or diffuse EEG abnormalities are present. In patients with unlocalizable epileptic abnormalities, palliation may be obtained by CC.