The structure of the common atrioventricular valve in hearts having isomeric atrial appendages and double inlet ventricle

The primary purpose of the study was to examine the role of the posterior cruciate ligament (PCL) in knee-joint proprioception after total knee arthroplasty (TKA). Knee-joint proprioception was measured in 10 patients with nonsacrificed PCL TKAs and 10 with sacrificed PCL TKAs. Knee-joint proprioception was evaluated through reproduction of static knee angles using a Penny and Giles electrogoniometer. The primary variable was absolute angular error (AAE). AAE was defined as the absolute value of the difference between the test angle and the patient's perceived version of the test angle. Proprioception deficit was compared to the WOMAC questionnaire which evaluates pain, stiffness, and physical function of the lower extremity. No significant difference was found between the nonsacrificed PCL TKA (4.33 degrees +/- 1.52 degrees) and sacrificed PCL TKA (4.38 degrees +/- 1.39 degrees) AAE values (P > .4). Furthermore, no significant differences were observed in the WOMAC questionnaire scores for all three parameters between the two types of knee prosthesis (P > .35). The current findings suggest that the preservation of the PCL in TKA may not improve knee-joint proprioception and subsequently may not improve TKA functional performance.     

Symptomatic intraarticular ganglia of the cruciate ligaments of the knee

This case report draws attention to the clinical presentation, differential diagnosis, and recommended diagnostic modality and treatment of symptomatic ganglia of the anterior and posterior cruciate ligaments. One patient presented with a recurrent inability to fully extend the left knee. Another patient presented with pain and soreness over the lateral aspect of the knee, including the lateral joint line. The diagnosis of ganglia of the cruciate ligaments was made after clinical, radiographic, and magnetic resonance examination. Both patients were treated successfully with resection of their ganglia using arthroscopic techniques.     

The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea

To determine the effect of anterior cruciate ligament (ACL) reconstruction on symptoms of pain and instability in patients with chronic ACL insufficiency who had previously undergone meniscectomy, we reviewed a series of 21 symptomatic, previously meniscectomized patients with chronic ACL deficiency (average age, 31 years). Arthroscopically assisted intra-articular ACL reconstruction using a middle, one-third patella-tendon autograft was performed in all cases. All patients had radiographic evidence of degenerative changes before ACL reconstruction. The average time from meniscectomy to ACL reconstruction was 6.6 years. Preoperative and postoperative range of motion, stability, and subjective evaluations were compared. Follow-up averaged 37.4 months (range, 24 to 67 months). Physical examination and postoperative KT-1000 side-to-side measurements revealed three patients (14%) with pathological ligament laxity. One patient had a 2+ Lachman, a 2+ pivot shift, and > 5 mm difference on KT-1000 maximum manual test, and two patients had a 1+ Lachman and a 1+ pivot shift. Range of motion measurements taken at follow-up were not significantly different from preoperative measurements (extension, P = .14; flexion, P = .46). Subjectively, all items on a panel of 15 visual analog scales were improved, but intensity of pain and instability were significantly improved after statistical analysis (P < .05). This review suggests that symptoms of pain and instability in patients with chronic ACL deficiency who have previously undergone meniscectomy can be improved by ACL reconstruction if objective stability is obtained.     

Flexion instability after primary posterior cruciate retaining total knee arthroplasty

Between 1990 and 1995, 25 painful primary posterior cruciate ligament retaining total knee arthroplasties were revised for flexion instability. These patients shared typical clinical presentations that included a sense of instability without frank giving way, recurrent knee joint effusion, soft tissue tenderness involving the pes anserine tendons and the retinacular tissue, posterior instability of 2+ or 3+ with a posterior drawer or a posterior sag sign at 90 degrees flexion, and above average motion of their total knee arthroplasty. The primary total knee arthroplasty was performed for osteoarthritis in 23 patients and rheumatoid arthritis in two patients. There were 13 male and 12 female patients and their mean age was 65 years (range, 35-77 years). Before the revision operation, Knee Society knee scores averaged 45 points (range, 17-68 points) and function scores averaged 42 points (range, 0-60 points). Twenty-two of the knee replacements were revised to posterior stabilized implants and three underwent tibial polyethylene liner exchange only. Nineteen of the 22 knee replacements revised to a posterior stabilized implant were improved markedly after the revision surgery. Only one of three knee replacements that underwent tibial polyethylene exchange was improved. After the revision for flexion instability, Knee Society knee scores averaged 90 points (range, 82-99 points) and function scores averaged 75 points (range, 45-100 points) for the 20 knees with a successful outcome. This study suggests that flexion instability can be a cause of persistent pain and functional impairment after posterior cruciate ligament retaining total knee arthroplasty. A revision operation that focuses on balancing the flexion and extension spaces, in conjunction with a posterior stabilized knee implant, seems to be a reliable treatment for symptomatic flexion instability after posterior cruciate retaining total knee arthroplasty.     

18th World Congress, member assembly 1996 and professional board meeting of Rehabilitation International (RI) 9/13-9/20 in Auckland, New Zealand

Anterior knee pain in our military population consititutes a diagnostic and therapeutic problem that is not always easily solved. In recent years, a better understanding of the biomechanics of the patello-femoral joint has contributed to the successful classification and treatment of many patients. However, the cause of pain remains elusive in a significant subset of patients who show no clinical or radiographic evidence of patellar malalignment and continue to have persistent pain despite adequate physiotherapy. In this article, the classification and approach to anterior knee pain are reviewed. Emphasis is placed on dividing patients into four subsets namely; normal tracking, patellar tilt, patellar subluxation and extra-articular causes of anterior knee pain. A more rational approach to the problem can then be employed and successful rehabilitation and/or surgery can be expected.     

Placental restriction alters adrenal medullary development in the midgestation sheep fetus

This is a retrospective study of 10 patients with combined cruciate ligament and posterolateral instability who underwent surgical reconstruction between 1991 and 1994. All knees had at least 20 degrees increased external rotation at 30 degrees of knee flexion and from 1+ to 3+ varus instability. Five knees with posterior cruciate ligament ruptures had at least a 2+ Lachman test result. (One knee had both anterior and posterior cruciate ligament injuries). In all cases the lateral collateral ligament was reconstructed with a bone-patellar tendon-bone allograft secured with interference screws. Fixation tunnels were placed in the fibular head and at the isometric point on the femur. The cruciate ligaments were reconstructed with autograft or allograft material. The average follow-up was 28 months. Excessive external rotation at 30 degrees of flexion was corrected in all but one knee. Six patients had no varus laxity, and four patients had 1+ varus laxity at 30 degrees of flexion. The posterior drawer test result decreased, on average, to 1+, and the Lachman test result decreased to between 0 and 1+. The average Tegner score was 4.6, with five patients returning to their preinjury level of activity and four returning to one level lower. These results indicate that this is a promising new procedure for patients with instability resulting from lateral ligament injuries of the knee.     

Effects of ketorolac on bone repair: A radiographic study in modeled demineralized bone matrix grafted rabbits

The treatment of instability of the multiply reoperated knee is a complex problem. The causes for failure are numerous and include repeated trauma, insufficient fixation and non-anatomic placement of the graft, inadequate replacement material, isolated anterior cruciate ligament (ACL) reconstruction in complex knee instability or the use of a ligament prosthesis. With every surgical procedure, however, the anatomical and technical conditions become worse. Problems like degenerative changes, joint stiffness and gait abnormalities occur and often become a more focal point than the instability itself. The purpose of this paper is to present the problems and the dilemma of instability of the multiply reoperated knee and the possible solutions. Between 1976 and 1996, a total of 1752 ACL reconstructions were carried out in Munich and Hannover. Of these, 228 (13%) were revision, mostly of failed ACL reconstructions performed elsewhere. Since 1989, we have chosen the severest cases from this group (more than three operations on the same knee) for this study. Seventeen patients were investigated who had undergone up to 25 operations. The mean number of operations was 7. All primary operations were performed in other hospitals. In 10 cases only the ACL reconstruction was performed as a final procedure, mostly in combination with other procedures like medial meniscus replacement, extra-articular stabilization or arthrolysis. In the other cases operations such as osteotomies, arthrodesis or amputation were necessary. The results present the main dilemma in instability of the multiply reoperated knee since they were not successful in all patients. Finally, 15 patients report still having instability, pain or swelling in isolation or in combination. Nine patients were satisfied with their subjective results. Even after the socalled definitive procedures, certain complications arose. The main goal in the treatment of instability of the multiply reoperated knee is to avoid a series of operations, hospitalization and history of illness. General revision surgery for the entire complaint is not the aim of the treatment. The specific problem of the patient should be extracted from the complex situation, and this should be solved with the most limited procedure possible only.     

Kinematics of posterior cruciate ligament-retaining and -sacrificing mobile bearing total knee arthroplasties. An in vitro comparison of the New Jersey LCS meniscal bearing and rotating platform prostheses

The posterior cruciate ligament (PCL)-retaining, meniscal bearing and the PCL-sacrificing rotating platform designs of the LCS prosthesis (DePuy, Warsaw, IN) were designed to minimally constrain knee kinematics while minimizing bone-cement-prosthesis interface stresses and polyethylene wear. The kinematics and stability of the knee following arthroplasty with these devices rely on adequate tensioning of the remaining soft tissues by management of the flexion/extension gaps at the time of surgery. In this in vitro study, the knee kinematics of the function of the quadriceps mechanism for 8 cadaveric knees were measured quantitatively before and after implantation of these 2 prosthesis designs. Following implantation of the PCL-retaining, meniscal bearing prosthesis, anterior translations during anterior drawer testing were significantly greater (P < .05) than those seen in the intact knee. Implantation of the PCL-retaining, meniscal bearing prosthesis resulted in an increase in the extension gap of 2 mm. Quadriceps force needed to achieve full extension was increased by 30% over that needed in the intact knee. The PCL-sacrificing, rotating platform prosthesis constrained anterior translation such that nearly normal anterior knee stability was reestablished; however, the extension gap was increased by 4 mm and the quadriceps force needed to achieve full extension was 50% greater than that needed in the intact knee. Attempts to achieve joint stability by increases in the thickness of the tibial component to widen the flexion/extension gaps results in compromises of quadriceps efficiency, particularly in the absence of a functioning PCL, as demonstrated in this in vitro model. Patients receiving the PCL-sacrificing prosthesis may experience difficulty in those activities requiring quadriceps power near full extension, such as rising from a chair or ascending or descending stairs.     

Long-term results after arthroscopic meniscectomy. The role of preexisting cartilage fibrillation in a 13 year follow-up of 60 patients

Sixty patients with stable knees and arthroscopic menisectomy were matched into two groups according to the presence of early degenerative changes at the operation. Patients with severe cartilage changes were excluded. The patients were between 20 and 40 years of age at the operation and no patient had previous surgery on the involved knee. The intraarticular findings were documented at surgery and the patients were re-examined 12 to 15 years after the meniscectomy. Pre-existing cartilage fibrillation at the meniscectomy did not seem to influence the long-term results. At the follow-up no difference was found between the groups at the physical examination, in subjective complaints, in knee function and activity or in radiographic findings. In the total group 62% had early signs of arthrosis (Fairbank changes) and 42% narrowing of the joint space (Ahlb?ck grade 1-2) in the operated knee. No one had more severe changes. Radiographic signs of arthrosis were 4 times commoner in the operated knee compared to the non-operated knee after partial meniscectomy and 7 times commoner in the operated knee after subtotal meniscectomy. Arthrosis at the follow-up was seen three times more often in patients older than 30 years of age at surgery than in younger patients. The functional outcome was good and 70% were still active in sports compared to 90% before the operation.     

Isolated tear of the anterior cruciate ligament: 5-year follow-up study

During the period 1967 to 1971, 64 cadets at the United States Military Academy, West Point, New York, had surgical repair for isolated tear of the anterior cruciate ligament. In a 5-year follow-up study to determine the functional impairment, present disability, and reinjury to the knee, 32 of the 64 patients were located and evaluated by radiographic examination and either by interview or by questionnaire. Twenty-two were commissioned to full duty. 23 had attended ranger or airborne school, and 16 had been in combat. Impairment of ordinary activities was noted by 12 and impairment of athletic endeavors by 24; pain by 71%; swelling by 66%; stiffness by 71%; and instability by 94%. Seventeen of the 32 had had a significant reinjury after the repair of the anterior cruciate ligament. Clinically, we can diagnose the isolated tear of the anterior cruciate ligament by four essential ingredients--a pop at time of injury, inability to continue participation, gross swelling of knee, and maximal swelling within 12 hr. The mechanism of injury is usually deceleration and change of direction, not contact with another player. The follow-up study on this small series indicates that the patients have progressive deterioration of the knee.     

Hypothermia in mitro-aortic valve surgery

A report of the results achieved by treating of corrosive diseases of knee joint by partial and total endoprosthesis. A total of 74 knee joints were operated on. Improvement of movement and stress capability was achieved in 93% of all cases. Complications are presented and discussed. Follow-up and summary of all cases reveals that the total endoprosthesis is increasingly indicated. The replacement of a sliding endoprosthesis by a total endoprosthesis has since become necessary in three cases and resulted in marked improvement of function. One patient is not free of complaints, and an exchange operation is indicated. The indications for implantation of a sliding endoprosthesis will in the future surely be much more closely drawn. Follow-up reveales that increasing reactive changes of the knee joint cause pain of increasing measure. An initially painless interval is followed by a period of increasing pain. Results of follow-uthesis may be extended. The continued pain that totally operated patients in part by the high-grade and progressive changes in the femoro-patellar joint.     

Anterolateral soft-tissue impingement in the ankle: diagnosis using MR imaging

OBJECTIVE: This study was performed to elucidate the MR imaging findings and pitfalls for the diagnosis of anterolateral soft-tissue impingement in the ankle, a cause of chronic ankle pain that can be relieved by arthroscopic resection. MATERIALS AND METHODS: We retrospectively reviewed MR imaging examinations of 18 patients with arthroscopically confirmed anterolateral ankle impingement. The MR images of 18 additional subjects with symptoms that could mimic anterolateral impingement, but who had a surgically confirmed alternate diagnosis (instability, peroneal tendon injury, osteochondral defect, normal arthroscopy) and no evidence of impingement at arthroscopy, served as controls. RESULTS: On the MR imaging studies, nine patients had an ankle effusion, eight of whom showed an abnormal soft-tissue structure in the anterolateral gutter, 2-15 mm in maximal diameter. No soft-tissue mass was seen in the patients without joint fluid. Four control subjects with instability had a similar soft-tissue structure in the anterolateral gutter, but in the control subjects the finding represented a portion of the torn anterior talofibular ligament. CONCLUSION: Anterolateral soft-tissue impingement of the ankle can be suggested by MR imaging when fluid in the lateral gutter outlines an abnormal soft-tissue structure separate from the anterior talofibular ligament.     

The painful arc syndrome. Clinical classification as a guide to management

Ninety-seven patients suffering from painful arc syndrome of the shoulder were studied. Local anaesthetic and radiographic contrast investigations were carried out. One-third of the patients had lesions in the posterior part of the rotator cuff which resolved after injections of local anaesthetic and steroid. One-third had anterior lesions in the subscapularis tendon: almost all resolved under the same regime but two required division of the coraco-acromial ligament. The remaining third had lesions of the supraspinatus tendon, usually associated with degeneration of the acromio-clavicular joint: most of these failed to gain relief from the local anaesthetic and steroid. Twenty-two operations were performed either by a transcromial or by a deltoid splitting approach. Excision of the outer end of the clavicle and division of the coraco-acromial ligament abolished the pain in most cases.     

Indications for surgical treatment of tibial condyle fractures

The residual radioanatomic changes influencing the functional, subjective, and clinical outcome of 131 tibial condyle fractures were studied. Clinical function was found to deteriorate rapidly with increasing values of residual medial tilt of the tibial plateau, whereas lateral tilt of the plateau was well tolerated up to 5 degrees. Articular step-off up to 3 mm and condylar widening up to 5 mm had no adverse effects. Seventy percent of knees with moderate or severe instability were functionally unacceptable. It was concluded that a medial unicondylar fracture with any displacement, and all medially tilted bicondylar fractures, should be operated upon. In fracture of the lateral condyle, open reduction and internal fixation is indicated when lateral tilt or valgus malalignment exceeds 5 degrees, articular step-off exceeds 3 mm, or condylar widening exceeds 5 mm. The same limits apply to laterally tilted bicondylar fractures, provided that the medial condyle is undisplaced. Any displacement seen in the axial bicondylar fracture is an indication for surgical treatment. If there is any mediolateral instability in the extended knee joint after rigid internal fixation, repair of a collateral ligament should be considered. An avulsed anterior cruciate ligament should be fixed, if pathologic laxity exists, but the torn ligament can be ignored and reconstructed later if needed.     

In vitro activities of antimicrobial agents against Candida species

A single surgeon's consecutive series of 50 arthroscopically repaired meniscal tears in 48 patients was retrospectively reviewed. None of these patients had concomitant ligament damage to the knee. The average follow-up period was 10 years, 9 months. Criteria for clinical success included 1) history of pain of grade 1 or less and absence of locking, catching, or giving way; 2) a physical examination demonstrating no significant effusion and a painless and negative jump sign; and 3) no subsequent surgical procedures on the repaired meniscus. Patient satisfaction was quite high, although clinical confirmation was possible in only 38 knees, indicating a clinical success rate of 76%. Bilateral standing radiographs were obtained on these 38 operated knees and were evaluated using Fairbank's classification. Evaluation of the radiographs revealed that 8% of the operated knees had minimal joint changes, as compared with 3% in the contralateral, nonoperated knee. This study demonstrates that arthroscopic meniscal repair in knees with isolated meniscal tears has the potential for a long-term successful clinical and radiographic outcome.     

Acute knee injuries: Part I. History and physical examination

A thorough history and physical examination are helpful in the diagnosis of meniscal damage, cruciate and collateral ligament sprains and patellar instability, the four major acute knee injuries. When performing a physical examination in a patient with a knee injury, the uninjured knee should always be assessed first and used for comparison. Examination includes passive and active range-of-motion testing, palpation of the joint line spaces, and a variety of maneuvers to evaluate knee stability. Valgus and varus testing provides assessment of the collateral ligaments. The Lachman and pivot shift tests are useful in the evaluation of the anterior cruciate ligament. The posterior drawer and tibial sag tests are used to evaluate the posterior cruciate ligament. The bounce test, McMurray's test and Apley's grind test can aid in the diagnosis of meniscal injury.     

Acute repair of injury to the anterior cruciate ligament. A long-term followup

We reviewed 30 patients at an average of 7.4 years after acute repair of the anterior cruciate ligament augmented with a loop of iliotibial tract. A noncontact twisting had been the mechanism of injury in 18 of these patients, with 28 having been injured in sports. At followup, 25 patients had not experienced symptoms of instability and 23 were able to return to unrestricted athletic activity; only 5 had been unable or unwilling to return to sporting activity at all. There had been no swelling in 23 patients; however, 17 suffered from pain on exertion. The average Lysholm score was 93.2. Joint laxity was assessed and anteroposterior tibial translation quantified with a KT-1000 arthrometer. Eighteen patients had a normal or 1+ Lachman test and 27 had an absent or 1+ pivot shift. When compared with the results of a similar study performed on this group of patients at 2 years after surgery, there had been little subjective change in knee function. However, objectively there had been significant deterioration of the anteroposterior stability of the knees at 7 years, suggesting failure of the integrity of the repaired ligament with time. An associated medial collateral ligament injury had a significant adverse effect both on the integrity of the anterior cruciate ligament repair and the incidence of postoperative stiffness.     

Midline osteotomy with lag screw stabilization for mandibular swing

Fifteen patients with recurrent inversion ankle sprains and documented lateral ankle instability were treated with an anatomically oriented ligament reconstruction using a split peroneus brevis tendon graft. This reconstruction is designed to augment repair of the anterior talofibular and calcaneofibular ligaments without restricting subtalar motion. Of the 12 patients available for long-term followup, all were functionally improved, with no recurrences of instability. Stress radiographic examination at followup confirmed that mechanical stability had been restored in all ankles. Eversion strength and subtalar joint motion were maintained after surgery. We recommend this procedure in patients who require augmented reconstruction of the lateral ankle ligaments.     

Internal derangement of the knee after ipsilateral femoral shaft fracture: MR imaging findings

OBJECTIVE: This study uses magnetic resonance (MR) imaging to delineate the types and frequencies of injuries seen in the knee after ipsilateral femoral shaft fracture. We also compare the results of the orthopedic knee examination with the MR findings. DESIGN AND PATIENTS: MR imaging of the ipsilateral knee was performed on 34 patients with closed femoral shaft fractures. Indications for knee MR imaging included knee pain at the time of fracture, soft tissue swelling or an effusion of the knee, or a positive knee examination under anesthesia. The patients had a mean age of 27 years and all were stabilized with intramedullary nails. Imaging was performed a mean time of 2.5 days after surgery. All patients had knee examinations done under anesthesia, and the MR results were compiled and compared with the clinical examinations. RESULTS: Ninety-seven percent of patients demonstrated knee effusions. Twenty-seven percent of patients demonstrated meniscal tears, with the posterior horn of the medial meniscus most frequently torn. The medial collateral ligament was the most frequent site of ligamentous injury (38%) followed by the posterior cruciate ligament (21%). Fifty percent of patients had injuries of the extensor mechanism. Bone bruises were noted in 32% of patients. Articular cartilage injuries were confined to the patella in four cases. One occult tibial plateau fracture and one meniscocapsular separation were seen. CONCLUSIONS: There is a common incidence of both ligamentous and meniscal injury to the knee after ipsilateral femoral shaft fracture. MR imaging can be useful in assessing the extent of injury, and may reveal findings unsuspected after clinical examination of the knee.     

Compatibility problems after intravenous immunoglobulin--a case report

The purpose of this study was to determine whether there are changes in anterior and posterior glenohumeral translation after arthroscopic, nonablative, thermal capsuloplasty with a laser. Two anteriorly and two posteriorly directed loads were sequentially applied to the humerus of nine cadaveric glenohumeral joints, and anterior and posterior translation of the humerus on the glenoid was measured. The glenoid was rigidly fixed, and the glenohumeral joint was positioned simulating 90 degrees of shoulder abduction and 90 degrees of external rotation. Using the holmium:yttrium-aluminum-garnet laser, thermal energy was then applied to the anterior capsuloligamentous structures and anterior and posterior translation measurements were then repeated. The results showed a significant reduction in anterior and posterior translation after laser anterior capsuloplasty. Anterior translation decreased from 10.9 +/- 2.0 mm (mean +/- SEM) to 6.4 +/- 1.5 mm with the 15-N load; and from 13.4 +/- 2.1 mm to 8.9 +/- 1.8 mm with the 20-N load. Posterior translation decreased from 7.2 +/- 1.2 mm to 4.4 +/- 0.6 mm with the 15-N load and from 10.4 +/- 1.4 mm to 6.5 +/- 0.9 mm with the 20-N load. These results indicate that the holmium:yttrium-aluminum-garnet laser can be used to decrease glenohumeral joint translation and may be an effective treatment for glenohumeral joint instability.