Clinical Signs Of Instability Research Articles

Coronal plane stability of cruciate-retaining total knee arthroplasty in valgus gonarthrosis patients: A mid-term evaluation using stress radiographs.

Total knee arthroplasty (TKA) using implants with a high level of constraint has generally been recommended for patients with osteoarthritis (OA) who have valgus alignment. However, studies have reported favorable outcomes even with cruciate-retaining (CR) implants. To evaluate the coronal plane stability of CR-TKA in patients with valgus OA at the mid-term follow-up. Patients with primary valgus OA of the knee who underwent TKA from January 2014 to January 2021 were evaluated through stress radiography using a digital stress device with 100 N of force on both the medial and lateral side. Gap openings and degrees of angulation change were determined. Descriptive statistical analysis was performed for both continuous and categorical variables. Inter-rater reliability of the radiographic measurements was evaluated using Cronbach's alpha. This study included 25 patients (28 knees) with a mean preoperative mechanical valgus axis of 11.3 (3.6-27.3) degrees. The mean follow-up duration was 3.4 (1.04-7.4) years. Stress radiographs showed a median varus and valgus gap opening of 1.6 (IQR 0.6-3.0) mm and 1.7 (IQR 1.3-2.3) mm and varus and valgus angulation changes of 2.5 (IQR 1.3-4.8) degrees and 2.3 (IQR 2.0-3.6) degrees, respectively. No clinical signs of instability, implant loosening, or revision due to instability were observed throughout this case series. The present study demonstrated that using CR-TKA for patients with valgus OA of the knee promoted excellent coronal plane stability.

Incidence of risk factors in developmental dysplasia of the hip: a retrospective study on 18,954 cases.

DDH is 1 of the most important causes of childhood disability. A diagnosis of instability can be made in the neonatal period via the Ortolani and Barlow manoeuvres. However, clinical examination, although highly specific, has poor sensitivity as compared to ultrasound. There is controversy between the necessity of universal screening for dysplasia of all newborns or selective screening reserved for those with clinical signs of instability or known risk factors of DDH. To analyse the risk factors of congenital hip dysplasia in a consecutive case series of children referred for diagnosis and treatment of DDH. This was a cross-sectional study on infants consecutively examined between January 2000 and December 2019 at the Marino Ortolani Centre in Ferrara, Italy. The first 3 types on Graf's classification were considered physiological (1A, 1B, 2A+), while the last 6 pathological (2A-, 2B, 2C, 2D, 3, 4). 18,954 infants met the inclusion criteria and were therefore considered eligible for the study. Of these 18,954 infants, 56% (n = 10,629) were females and 44% (n = 8325) were males. According to Graf classification, 34.9% (n = 6621) were 1A, 52.7% (n = 9999) were 1B, 4.0% (n = 753) were 2A+, 2.5% (n = 478) were 2A-, 1.5% (n = 284) were 2B, 1% (n = 196) were 2C, 1.3% (n = 243) were 2D, 1% (n = 193) were 3 and 1.0% (n = 187) were 4. The most significant risk factor was the female gender (OR 5.36; 95% CI, 4.63-6.20) followed by a family history (OR 2.35; 95% CI, 2.08-2.65), then skeletal pathologies (OR 2.04; 95% CI, 1.21-3.42), oligohydramnios (OR 1.75; 95% CI, 1.44-2.13), and finally breech presentation (OR 1.42: 95% CI, 1.27-1.60). Based on our data, family history, musculoskeletal disease, oligohydramnios and breech presentation are the main risk factors for DDH development, as is the female sex.

A Novel Integrated Clinical-Biochemical-Radiological and Sonographic Classification of Necrotizing Enterocolitis.

To evaluate the sensitivity and specificity of clinical, laboratory, and radiological markers and the neonatologist-performed intestinal ultrasound (NP-IUS) for treatment interventions in preterm neonates who developed necrotizing enterocolitis (NEC). This was a case-control study of preterm neonates < 35 weeks with a diagnostic workup for NEC. The diagnostic workup included NP-IUS performed by trained neonatologists using a standard protocol, abdominal roentgenogram (AXR), and laboratory investigations. Intestinal ultrasound (IUS) performed by two neonatologists was standardized to detect 11 injury markers. AXRs were read independently by experienced pediatric radiologists. The investigators who retrospectively interpreted the IUS were blinded to the clinical and treatment outcomes. A total of 111 neonates were assessed. Fifty-four did not require intervention and formed the control group. Twenty cases were treated medically, 21 cases were treated with late surgery for stricture or adhesions, and 16 were treated with early surgery. The integrated model of cumulative severity of ultrasound markers, respiratory and hemodynamic instability, abdominal wall cellulitis, and C- reactive protein > 16 mg/L had an area under the curve (AUC) of 0.89 (95% confidence interval [CI]: 0.83-0.94%, p < 0.0001) for diagnosing NEC requiring surgical intervention. We also investigated the utility of Bell's classification to diagnose either the need for surgery or death, and it had an AUC of 0.74 (95% CI: 0.65-0.83%, p < 0.0001). In this cohort, a combination of specific IUS markers and clinical signs of instability, abdominal wall cellulitis, plus laboratory markers were diagnostic of NEC requiring interventions. · The diagnosis of necrotizing enterocolitis requires a combination of markers.. · The combination of specific ultrasound markers, clinical signs, and laboratory markers were diagnostic of NEC requiring intervention.. · The intestinal ultrasound performed by a trained neonatologist was the most sensitive diagnostic marker of NEC requiring surgical intervention..

Surgery for basilar invagination with and without Chiari I malformation.

The surgical treatment for Chiari I malformation and basilar invagination has been discussed with great controversy in recent years. This paper presents a treatment algorithm for these disorders based on radiological features, intraoperative findings, and analyses of long-term outcomes. Eight-five operations for 82 patients (mean ± SD age 40 ± 18 years; range 9-75 years) with basilar invagination were evaluated, with a mean follow-up of 57 ± 55 months. Apart from the radiological features and intraoperative findings, findings on neurological examinations before and after surgery were analyzed. Long-term outcomes were evaluated with Kaplan-Meier statistics. All 77 patients with a Chiari I malformation underwent foramen magnum decompression with arachnoid dissection and duraplasty. Patients with ventral compression by the odontoid peg were managed with posterior realignment and C1-2 fusion. Patients without ventral compression did not undergo C1-2 fusion unless radiological or clinical signs of instability were detected. Thirty-three patients without ventral compression or instability underwent foramen magnum decompression without additional fusion, whereas 52 operations on 49 patients involved posterior fusion at C0-2 or C1-2 after realignment of ventral compression and/or treatment of C1-2 instability. Postoperatively, gait ataxia, swallowing functions, and suboccipital pain improved significantly in both treatment groups. In total, 79% and 73% of patients reported that their condition improved after foramen magnum decompression alone and after fusion with or without foramen magnum decompression, respectively. Progression-free survival rates at 10 years were 83% and 81%, respectively. Among the patients with basilar invagination, a subgroup consisting of 40.2% of the included patients underwent successful long-term treatment with foramen magnum decompression alone and without additional fusion. This subgroup was characterized by the absence of a ventral compression and no atlantoaxial dislocation or other signs of craniocervical instability. The remainder of patients underwent C1-2 fusion with posterior realignment of ventral compression if required. In the presence of basilar invagination, Chiari I malformation should be treated with foramen magnum decompression and duraplasty.

Combined treatment with medial unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction is effective on long-term follow-up

PurposeThe purpose of the present study was to evaluate the long-term outcome of combined medial unicompartmental knee arthroplasty (UKA) and anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that the combined procedure leads to good long-term outcome in patients with isolated medial knee osteoarthritis (OA) and anterior cruciate ligament (ACL) deficiency.MethodsTwenty-three patients with ACL deficiency and concomitant medial knee OA were treated from 2008 to 2016 with a combined UKA (Oxford Partial Knee) and ACLR using a hamstring tendon autograft. The follow-up assessment included VAS pain score, Lysholm score, Oxford Knee Score (OKS), American Knee Society scores (AKSS), International Knee Documentation Committee (IKDC 2000), Tegner and UCLA activity scores. Instrumented laxity test was done using the KT-1000 arthrometer. Survivorship analysis was performed using the Kaplan–Meier method. Implant loosening and disease progression was assessed by conventional radiography.ResultsAverage follow-up duration was 10 years (6–14.5). VAS, Lysholm, Tegner and UCLA scores improved significantly. OKS, AKSS and IKDC 2000 showed excellent results on follow-up. Implant survivorship was 91.4% at 14.5 years. There were 2 revisions with conversion to total knee arthroplasty at 6 and 12 years postoperatively due to trauma and disease progression, respectively. There were no radiological or clinical signs of instability or disease progression in any of the remaining knees. The side-to-side difference using the KT-1000 arthrometer was insignificant.ConclusionsUKA combined with ACLR is an effective therapeutic option with good outcome and return to sport rate on the long-term.Level of evidenceIV.

Glycerin suppositories used prophylactically in premature infants (supp): A pilot randomized controlled trial

Glycerin suppositories are often used to facilitate meconium evacuation in premature infants. The evidence for this practice is inconclusive. The purpose of this study was to assess the feasibility of a multicenter randomized controlled trial on the effectiveness of this treatment strategy. We conducted an external pilot study for a multicenter randomized controlled trial of premature infants randomized to glycerin suppositories or placebo procedure. Participants were included if they were gestational age of 24 weeks 0 days to 31 weeks 6 days and/or birthweight of 500 to 1500 grams. We excluded infants with life-threatening congenital anomalies, contraindications to receiving suppositories, or signs of clinical instability. Outcomes included cost, recruitment, and treatment-related adverse events. A total of 109 were screened, 79 were initially eligible, and 34 consented to participate. Four of these infants were excluded prior to randomization due to thrombocytopenia, 30 were randomized, and 26 reached full enteral feeds. Three infants (10%) experienced rectal bleeding 5 to 43 days after completing study treatments. An anal fissure was noted in two of these patients. There were no cases of rectal perforation but one infant assigned to active treatment developed necrotizing enterocolitis. Conducting a multicenter randomized controlled trial on the use of glycerin suppositories in premature infants is feasible. Minor modifications to the study protocol are needed to increase participant recruitment and simplify the administration of study treatments.

CT-based morphometric analysis of C1 laminar dimensions: C1 translaminar screw fixation is a feasible technique for salvage of atlantoaxial fusions.

Background:Translaminar screw fixation has become an alternative in the fixation of the axial and subaxial cervical spine. We report utilization of this approach in the atlas as a salvage technique for atlantoaxial stabilization when C1 lateral mass screws are precluded. To assess the feasibility of translaminar fixation at the atlas, we have characterized the dimensions of the C1 lamina in the general adult population using computed tomography (CT)-based morphometry.Methods:A 46-year-old male with symptomatic atlantoaxial instability secondary to os odontoideum underwent bilateral C1 and C2 translaminar screw/rod fixation as C1 lateral mass fixation was precluded by an anomalous vertebral artery. The follow-up evaluation 2½ years postoperatively revealed an asymptomatic patient without recurrent neck/shoulder pain or clinical signs of instability. To better assess the feasibility of utilizing this approach in the general population, we retrospectively analyzed 502 consecutive cervical CT scans performed over a 3-month period in patients aged over 18 years at a single institution. Measurements of C1 bicortical diameter, bilateral laminar length, height, and angulation were performed. Laminar and screw dimensions were compared to assess instrumentation feasibility.Results:Review of CT imaging found that 75.9% of C1 lamina had a sufficient bicortical diameter, and 63.7% of C1 lamina had sufficient height to accept bilateral translaminar screw placement.Conclusions:CT-based measurement of atlas morphology in the general population revealed that a majority of C1 lamina had sufficient dimensions to accept translaminar screw placement. Although these screws appear to be a feasible alternative when lateral mass screws are precluded, further research is required to determine if they provide comparable fixation strength versus traditional instrumentation methods.

Tibial tunnel widening after hamstring anterior cruciate ligament reconstructions: Comparison between Rigidfix and bio-Transfix

BackgroundThere is no study comparing tibial tunnel widening after hamstring anterior cruciate ligament (ACL) reconstructions between RigidFix(r) and Bio-TransFix(r). MethodsHamstring ACL reconstructions using RigidFix(r) in 56 patients and Bio-TransFix(r) in 41 with a minimum of 2years postoperative evaluation were reviewed. Tibial fixation was performed using Intrafix in both groups. On the anterior–posterior (AP) and lateral radiographs, the diameter of the tibial tunnel was measured at proximal, middle, and distal positions. Postoperative laxity evaluations were performed using Lachman test, pivot-shift test, and instrumented laxity testing using the KT-1000 arthrometer. ResultsOn the AP and lateral radiographs, the average diameter of the tibial tunnel in the Bio-TransFix(r) group significantly increased after 6months compared to the immediate postoperative measurement (p=0.002 and p=0.002, respectively). However, the average diameter of the tibial tunnel in the RigidFix(r) group did not increase after 6months compared to the immediate postoperative measurement. Tunnel widening at 12months postoperatively in the Bio-TransFix(r) group was significantly more than that of the RigidFix(r) group on AP and lateral radiographs (p=0.012 and 0.016, respectively). Tunnel widening at 24months postoperatively showed a significant difference between the two groups (p=0.000 and 0.000, respectively). Fifteen patients (36.6%) in the Bio-TransFix(r) group and 15 patients (26.8%) in the RigidFix(r) group showed tunnel widening. There were no significant differences in results of the Lachman and pivot-shift tests, and mean KT-1000 measurement between the two groups. ConclusionThe Bio-TransFix(r) group showed progressive tibial tunnel widening after 6months postoperatively but no clinical signs of instability. Level of evidenceLevel III.

Computernavigierter Gelenkersatz am Knie mit dem Orthopilot®

Reproducible, precise implantation of a bicondylar knee prosthesis considering size of implant, axial conditions in coronal and sagittal planes, rotation, and ligament tension in extension and flexion. Progressive painful gonarthrosis, when conservative treatment is no longer an option. Revision of unicondylar prosthesis. General contraindications to bicondylar knee replacement. Revision after bicondylar replacement. Severe limitation of hip joint mobility, e.g., after arthrodesis of the hip joint or ipsilateral hip joint ankylosis. Morbid obesity. Approach to the knee joint for alloarthroplasty. Placement of the screws and fixation of the infrared reflectors at femur and tibia. After adjustment of the double camera, collection of kinematic data via standardized motion patterns and identification of predetermined anatomic landmarks at the knee and ankle joint. By means of this data, controlled resection of the tibia, determination of the ligament tension in extension and flexion, planning of the femoral osteotomies, controlled distal resection of the femur. Following intraoperative verification of the distal femur resection, navigation of the position of the femur to complete femoral resection. Placement of the trial components, determination of the tibial onlay thickness, adjustment of the rotation of the tibial component, and final preparation of the tibial shaft. Preparation of the patella by resection of osteophytes, denervation, and possibly onlay patellar resection using a saw. Finally, implantation of the tibial component (cemented or noncemented), the tibial onlay, the femoral component (cemented or noncemented), and possibly cementation of the patellar onlay. After hardening, control of knee movement in straight position and wound closure in layers. Early functional treatment using continuous passive motion device. Pain-adapted increase of weight bearing. Low-molecular-weight heparin for 5-6 weeks. Meanwhile, several studies have demonstrated that computer navigation helps to provide more accuracy in implant positioning, compared with conventional techniques in total knee replacement. Long-term survival of the implants promises to be superior after physiological leg axis restoration. Own results: 100 consecutive implantations: average duration of surgery 80 min, blood loss 360 ml, one deep infection (healed after early revision), one arthrofibrosis requiring revision surgery, average range of motion on the day of discharge 110 degrees in flexion (90-120 degrees) and full extension, after 3 months average 125 degrees in flexion (90-140 degrees). No clinical signs of instability. Postoperative radiologic evaluation with standard radiographs of the knee joint in coronal and sagittal planes took place right after surgery and again after 3 months.

Clinical and radiological instability following standard fenestration discectomy

Background:Post-surgical lumbar instability is an established complication but there is limited evidence in the literature regarding the incidence of lumbar instability following fenestration and discectomy. We analyzed our results following fenestration discectomy with a special focus on instability.Materials and Methods:Eighty-three patients between the age of 17 and 52 years who had undergone fenestration discectomy for a single-level lumbar intervertebral disc prolapse were followed-up for a period of 1–5 years. The criteria for instability included “instability catch,”, “painful catch,” and “apprehension.” The working capacity of the patient and the outcome score of the surgery were assessed by means of the Oswestry disability score and the Prolo economic and functional outcome score. Flexion-extension lateral radiographs were taken and analyzed for abnormal tilt and translation.Results:Of the 83 patients included, 70 were men and 13 were women, with an average age of 37.35 years (17–52 years) at 5 years follow-up. Clinical instability was seen in 10 (12.04%) patients. Radiological instability was noted in 29 (34.9%) patients. Only six (60%) of the 10 patients who demonstrated clinical instability had radiological evidence of instability. Twenty (68.96%) patients with radiological instability were asymptomatic. Three (10.34%) patients with only radiological instability had unsatisfactory outcome. The Oswestry scoring showed an average score of 19.8%. Mild disability was noted in 59 (71.08%) patients and moderate disability was seen in 24 (28.91%) patients. None of the patients had severe disability. These outcomes were compared with the outcomes in other studies in the literature for microdiscectomy and the results were found to be comparable.Conclusion:The favorable outcome of this study is in good agreement with other studies on microdiscectomy. Clinical instability in 12.04% of the patients is in agreement with other studies. Radiological signs of instability are seen even in asymptomatic patients and so are not as reliable as clinical signs of instability. Standard fenestration discectomy does not destabilize the spine more than microdiscectomy.

COMPLICATIONS RESULTING FROM THE USE OF METAL ANCHORS IN SHOULDER ARTHROSCOPY

To identify the complications concerning the use of metal anchors in shoulder arthroscopic procedures. Methods: 28 shoulders of 28 patients (23 male and 5 female) have been re-operated in the period between December 1997 and August 2007, at Hospital Ortopédico, Belo Horizonte Hospital and Military Police Hospital in Belo Horizonte, MG, as a result of complications such as loose anchors and prominent anchors. The primary surgeries intended to treat 20 anterior traumatic instabilities (71.5%), one posterior instability (3.5%), one slap injury (3.5%), six procedures for treating injuries on the rotator cuff (21.5%). We used the X-ray classification suggested by Samilson and Prieto and Outerbridge arthroscopic classification for assessing patients' degree of arthrosis. All patients were evaluated by the UCLA (University of California at Los Angeles) index criteria. Results: In all patients, arthroscopic reviews were made. In two cases, after anchors removal, clinical signs of instability were seen, leading to the decision of providing open stabilization by Latarjet-Patte technique. Conclusion: the complications with metallic-suture anchors result from inappropriate surgical techniques applied in arthroscopy.

Perfil epidemiológico e evolução clínica pós-parto na pré-eclâmpsia grave

To describe maternal characteristics and blood pressure behavior in the puerperium of women admitted, during pregnancy, with diagnosis of severe preeclampsia.A cohort study was conducted including pregnant women with gestational age of 28 weeks or more, with diagnosis of preeclampsia, not in labor, at the Instituto Materno Infantil Professor Fernando Figueira (IMIP) from November 2006 to September 2007. Patients with chronic hypertension, autoimmune diseases, gestational diabetes, multiple pregnancy and signs of clinical instability were excluded. Biological, demographic and obstetrical characteristics were analyzed, as well as the behavior of systolic and diastolic blood pressure post partum.154 patients with severe preeclampsia were included. The mean maternal age was 25.1 + 6.5 years. Regarding education only 45.5% had completed 11 years of schooling. Only 20.1% of deliveries were vaginal and preterm newborns occurred in 59.8% of cases. Two cases of eclampsia, eighteen cases of HELLP syndrome and 43 cases of oliguria were registered. Length of post partum hospital stay varied from one to 30 days, and 45% of patients were in hospital until the seventh day after delivery. Hypertensive emergencies were registered in 53.9% of the patients during puerperium and use of antihypertensive drugs was maintained in 76.5% of the women.Preeclamptic women tend to have controlled blood pressures after the third day of puerperium and are likely to be discharged from hospital still using anti-hypertensive drugs. Key-words: Severe preeclampsia, post partum period complications.

The diagnosis and management of congenital dislocation of the hip

Congenital dislocation of the hip (CDH) or developmental dysplasia of the hip (DDH) is a common condition that encompasses a spectrum of pathology affecting the neonatal hip. Clinical signs of instability may be difficult to detect at birth using the Barlow Ortolani test. A clear imperative is to make an early diagnosis since delay after 3 months is synonymous with the necessity for surgery and also leads to a compromised prognosis. There is considerable controversy about clinical screening for DDH or ultrasound screening, either comprehensive or selective. Risk factors – such as breech presentation, oligohydramnios and talipes – are well known and there is some evidence that selective screening for these babies with ultrasound may assist diagnosis. The incidence of neonatal hip instability is around 15–20 per 1000 live births but that of established dislocation 1–2 per 1000 live births in unscreened cohorts. The usual early treatment is with the Pavlik harness but after 3 months, surgery – either an open or closed reduction – is necessary and in some surgically untreated children, secondary procedures such as pelvic osteotomy are necessary.

The association of subacromial dimples with recurrent posterior dislocation of the shoulder

Posterior positional dislocation is a form of atraumatic posterior recurrent dislocation commonly presenting in late teenage years. It has been an observation of ours that patients with posterior positional dislocation may have a small skin dimple, or tether, over the posteromedial deltoid of both shoulders. Fourteen consecutive patients with an established diagnosis of recurrent posterior positional dislocation were taken from our diagnostic database and reviewed along with 14 age- and sex-matched controls. For each patient and control, a diagnostic battery of clinical signs of instability was recorded and a photograph taken of the posterior aspect of the shoulder. The posterior dimple sign was associated with posterior instability with a sensitivity of 67% and a specificity of 92%. The clinical association of a posterior skin dimple and posterior recurrent positional dislocation has not been recognized before. This feature is discussed and the literature is reviewed.

Isolated fracture of the posterolateral tibial lip (Volkmann's triangle).

To retrospectively evaluate the underlying pathomechanism of isolated fracture of the posterolateral tibial lip (Volkmann's triangle), and to demonstrate associated radiographic methods. Retrospective analysis of 2500 ankle lesions showed an isolated fracture of the dorsal tibial lip in 25 cases. Distal tibial lesions of growing individuals were not considered. All patients were examined by radiography in internal oblique and lateral views. Sixteen of 25 patients had had their accident during winter; 11 had slipped on ice or snow. All 25 patients showed a closed ankle lesion in the correct joint position with no clinical signs of instability. Evaluation of the standard images showed isolated fracture of the posterolateral tibial lip in 24 patients. The fracture was best recognized in the standard lateral view in 22 patients. In 2 patients the lateral stress projection demonstrated the fracture (20 degrees internal rotation). In one case the fracture was only seen on axial CT images. Twenty-two patients with small wedge fragments were treated conservatively; 3 with a displaced and large fragment had surgical revision and stabilization. Sixteen cases were examined by conventional radiography at follow-up examination and 5 of these showed radiological signs of arthrosis. Plain conventional radiography is still necessary in the primary diagnosis of ankle joint lesions. The isolated fracture of the dorsal tibial margin is best seen in the standard lateral view. Indication for CT in routine diagnostics is limited to cases showing clinical evidence of ankle injury without roentgenological signs of a fracture in the standard images. Differential diagnoses include the pilon lesion and the Maison-neuve-type fracture.

Spinal stability after war missile injuries of the spine.

Spinal stability after surgery for war missile wound to the spine is addressed in this study. A retrospective 4-year analysis of 21 patients. The most common injuries were of the thoracic and lumbar spine. The injuries were frequently associated with the lesions of other organs. We registered extensive initial neurologic deficit in 47.6% of cases. All the patients were treated surgically. A decompressive laminectomy was performed in 80.9% of cases. Internal stabilization after laminectomy was performed in only one patient in our series. None had clinical signs of instability. There were no radiologic signs of postoperative spinal instability found on mean follow-ups of 15 months. Wound debridement with or without removal of bony and foreign body fragments from the spinal canal was performed. A laminectomy is considered a method of choice. The spine was not stabilized in most patients because the facet joints were left intact.

Anterior Instability of the Knee Despite an Intensive Rehabilitation Program

To investigate if an intensive rehabilitation program has a positive influence on the late course of an old, isolated anterior cruciate ligament rupture, patients were evaluated at an average of 8 years after injury. Seventy-five percent had acquired the injury during sporting activities. After diagnostic arthroscopy, which was done at an average of 163 days after the injury, the patients immediately were assigned to an intensive rehabilitation program. At the followup examination, none of the patients had an excellent result as determined by the Swiss Knee Group Score; 6 patients had a good result; 13 had a fair result; and 8 had a bad result. Fourteen patients had a partial meniscectomy during the followup period, and 4 had positive signs for meniscal lesions at the followup examination. In 52% of the patients gonarthrosis had advanced 2 stages, and in 26% it had advanced 3 stages. There was a significant correlation between worsening of gonarthrosis and previous meniscectomy, poor evaluation scores, and clinical signs of instability. Even an intensive rehabilitation program cannot prevent secondary lesions of the meniscus with ensuing joint degeneration. Thus, immediate operative reconstruction of old ruptured anterior cruciate ligaments is recommended.

Abdominal surgical controversies in the ICU patient

The optimal management of patients in intensive care presenting with acute abdominal disorders requires the cooperation of physicians, surgeons, anaesthetists and radiologists from the start, because their vigilance, expertise and contributions are complementary. Unfavourable pre-existing factors, the severity of the primary pathology and its complications, as well as the presence of multiorgan failure frequently contribute to an individualized approach in critically ill patients. Ethical aspects, though very important, are beyond the scope of this chapter, which reviews actual surgical problems and controversies. In order to identify an abdominal source of sepsis, ultrasound is the imaging modality of choice for the right upper quadrant, flanks and pelvis in the presence of localizing signs. If an ultrasound scan is negative, computed tomography should be performed in order to detect suspected but more subtle abnormalities. In the absence of localizing signs, but with signs of clinical instability, an eventually positive blood culture or some degree of multiple organ failure, an ultrasound scan of the right upper quadrant, flanks and pelvis should be followed by CT scanning of the upper and middle abdomen. If, by exclusion, the septic state is suspected to be of abdominal origin, peritoneal lavage should be considered in the non-surgical patient and a complete exploratory laparotomy in the postoperative patient. Multiple planned reoperations are required to treat the local pathology of advanced diffuse peritonitis or pancreatic necrosis. They allow early detection and correction of poorly controlled septic foci and secondary abdominal sepsis. Mycotic infection and increased intra-abdominal pressure deserve more attention and early treatment. Abdominal abscesses are drained percutaneously when appropriate, surgically when necessary. A septic state should resolve within 1–2 days after drainage; if not, comprehensive abdominal exploration has to be considered after exclusion of a causative extra-abdominal focus. Percutaneous cholecystostomy is the treatment of choice for uncomplicated acalculous cholecystitis; cholecystectomy is mandatory if gangrenous cholecystitis or perforation is suspected. Massively bleeding stress ulcers fortunately have become very rare since the introduction of routine ‘prophylaxis’; however, where this complication does occur, it frequently represents a final event. Colonic pseudo-obstruction can usually be managed by non-operative measures, including endoscopy; when this fails, surgery is indicated, certainly if caecal gangrene and perforation are suspected.

A combined intra- and extra-articular reconstruction using a carbon-dacron composite prosthesis for chronic anterior cruciate instability

Fifty patients with chronic symptomatic anterior cruciate insufficiency underwent ligamentous reconstruction using the "Westminster Composite Prosthesis" which consists of a central core of carbon fibre with an external weave of polyester. In 42 patients, the prosthesis was used as an augmentation within a tube of ilio-tibial tract, combined with a MacIntosh's extraarticular reconstruction. The prosthetic replacement alone was used in eight patients where there had been a previous extraarticular reconstruction and was associated with only fair results. The average age of the patients at operation was 28.5 years (range 18 to 50 years); instability of the knee had been present for a mean of 5.3 years and the average follow-up was 3.8 years (range 2 to 6 years). Assessment included subjective functional rating (Lysholm knee score) and clinical examination for instability. Thirty-seven patients (74%) had a good or excellent result, 11 (22%) had a fair result and two (4%) had a poor result. The Lachman test was grade I or less in 35 patients and the pivot shift sign was eliminated in 37 patients. Clinical signs of instability correlated well with the Lysholm knee score (p less than 0.001). Twenty-two unselected patients (44%) underwent an arthroscopic assessment and biopsy of the "neoligament" at an average of 10.4 months post-operatively. The prosthesis was found to be stable and well covered by a thick fibrous sheath ("neoligament") in 19 patients. The prosthesis was partially ruptured in two patients and completely disrupted in one. Thirty-two patients (64%) returned to their previous sports and 13 of them (26%) achieved their pre-injury level of performance.(ABSTRACT TRUNCATED AT 250 WORDS)