Abstract:

Brachial plexus surgery has been performed since the first half of our century, but initially the procedure was a rudimentary technique. Results were very poor, in fact, because of insufficient knowledge of the anatomy of the brachial plexus, of the pathophysiology of nerve regeneration and because of inadequate means of diagnosis and lack of modern sophisticated surgical equipment. Because of the poor results, a group of outstanding orthopedic surgeons wrote, in the sixties, an official agreement stating that brachial plexus surgery was useless and should be abandoned. Nevertheless, even though obstetrical palsies were on the decline due to the increase in Cesarean sections, the need for brachial plexus surgery was on the rise with the dramatic increase in the number of car and motorcycle accidents.

Authors:

Giorgio A. Brunelli, M.D., Brescia University Medical School, Brescia, Italy, Adolfo Vigasio, M.D., Giovanni R. Brunelli, M.D., Ospedale Civile di Brescia, Brescie, Italy

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Abstract:

The current success of total knee arthroplasty (TKA) as a solution for arthritic problems about the knee is reflected in the increasing number of these procedures. The 1992 annual hospital discharge summaries indicate approximately 160,000TKAs were performed in the United States for both primary and revision indications. Clinical success ofTKA is rooted in a refined appreciation of patient habitus, technical proficiency and implant design. The understanding of this integrated triad has evolved over the past two decades. The evolution of knee implant design reflects recognition of the principle that implant geometry, acting in concert with surrounding soft tissues, determines the joint stability, range of motion and implant/bone interface forces. Interchangeable plateau geometries associated with modular designs, represent a recent development which permit an optimization of these interactions for a specific patient pathology. This paper describes a comparative evaluation of the geometrical constraint offered by six primary modular knee systems and describes their clinical applicability.

Authors:

Paul D. Postak, B.Sc., Christine S. Helm, M.D., A. Seith Greenwald, D. Phil. (Oxon) The Mount Sinai Medical Center, Cleveland, OH

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Abstract:

Total joint replacement has become one of the more common orthopaedic operations, with approximately 240,000 major joint arthroplasties performed annually in the United States, a large percentage of these being of the hip. The vast majority of hip replacements are for the diagnosis of degenerative arthritis and are performed in patients greater than 60 years of age. Less commonly the procedure is performed for other diagnoses (eg, developmental disorders of the hip, inflammatory arthritis, and post-traumatic arthritis) and in younger patients. Each of these diagnoses are associated with unique characteristics posing an array of technical challenges for the surgeon. The purpose of this manuscript is to highlight the more common of these processes with emphasis on the technical difficulties encountered when reconstructing these hips.

Authors:

Erik T. Otterberg, M.D., Kevin L. Garvin, M.D., University of Nebraska Medical Center, Omaha, NE

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Abstract:

Looking at the drawings in Hey Groves' pioneering (1920) description of cruciate ligament reconstruction, it is obvious that what the author had in mind was insertion of the anterior cruciate ligament (ACL) at the anatomical attachment sites, even though he did not make that point in so many words. Palmer was the first to stress the importance of precise drill-hole placement in 1938,and to design his own drill guide to obtain this precision. And only in the last 10years have the biomechanical principles of accurate cruciate reconstruction been established. The term "isometry" was coined to express the need for a near-constant distance between the femoral and tibial attachments of the substitute ligament throughout the range of knee movement. In practice, however, ideal isometry is impossible to achieve, and length variations of up to 2mm are often acceptable. Both the anterior and the posterior cruciate ligament are made up of several bundles, with each bundle consisting of a large number of fibrils. There is no point in the range of movement, including full extension, at which all the ACL fibers would be taut; throughout the range, some fibers will be tense, while others will be slack. The greater part of the stress is taken by the anteromedial bundle; these are the fibers that are tense in full extension. This is why Friederich. et al. recommend ACL reconstruction with drill holes within the proximal and distal attachments of the native anteromedial bundle. Hefzy, et al. tried to determine the factors that affect the region of most isometric femoral attachments of the ACL. They noted that there is no completely isometric attachment. Kentsch and Muller described for the first time a technique for replacing both the anteromedial and the posterolateral bundle using a split patellar tendon graft. One strip would be positioned over the top, the other through a transcondylar tunnel. However, this technique is very difficult and time-consuming.

Authors:

Hans H. Paessler, M.D., ATOS-Klinik, Heidelberg, Germany

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Abstract:

Techniques for the repair and reconstruction of the anterior cruciate ligament (ACL) have advanced rapidly in the last decade. The procedure for ACLreconstruction and its equipment have become progressively sophisticated from what was once an open surgery requiring dislocation of the patella to the point where ACL reconstruction surgery can now be performed endoscopically through one small incision. By avoiding a superior /lateral incision through the quadriceps muscle, the endoscopic technique provides the advantages of reduced soft tissue morbidity, reduced pain and improved cosmetic appearance for the patient, and reduced costs due to the fact that the procedure can be performed on an outpatient basis. However, the success of the procedure in restoring normal stability and function to the knee is still based on the variables of graft type, placement, tension, and fixation, as well as postoperative rehabilitation. Numerous studies have provided valuable information regarding advancements in the surgical technique and rehabilitation for ACLreconstruction surgery. Regardless, variable success rates continue to be reported. For failures occurring within the first six months after surgery, graft fixation failure has been shown to be the major cause.

Authors:

Lonnie Paulos, M.D., Ann Greenwald, M.S., The Orthopedic Specialty Hospital, Salt Lake City, UT

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Abstract:

From its inception in 1911, the topic of spinal fusion has seemingly been shrouded in controversy. In that year, Dr. Russell Hibbs performed the first human spinal fusion on a patient with spinal tuberculosis. This spawned a debate over the procedure that led to the denial of Hibbs' membership to the American Orthopedic Association. the Association after ten years of debate. The procedure (and Hibbs' appointment to the AOA)was validated by The debate over spinal fusions is manifold to this date. The literature is replete with differing opinions regarding the indications, techniques and outcomes of spinal fusions. The topic is further compounded by the fact that the specifics of a spinal fusion are often distinct to the area of the spine fused.

Authors:

William F. Lestini, M.D., James S. Fulghum. III, M.D., Lee A. Whitehurst, M.D., Raleigh Community Hospital, Raleigh, NC, Triangle Back Care Center, Raleigh, NC

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Abstract:

The attachment of soft tissue to bone is a problem in orthopedic surgery. Over the last one hundred years several methods have been used. The earliest method involved drilling a hole in the bone, pulling the tendon through the hole and sewing the tendon onto itself. While this worked on tendon transfers, it did not work particularly well around the knee, shoulder and the ankle where there are large areas of cancellous bone and the tissue to be reattached is ligamentous and is less well-defined than a tendon. The second method was to split the periosteum, prepare a trough in the bone, and sew the tendon or the soft tissue directly into the periosteum. This method requires long immobilization of the joint, and while it does work, the immobilization often leads to arthrofibrosis. Staples, nails, tacks, and other devices have been used to attach soft tissue with various degrees of success.

Authors:

Willliam S. Ogden, M.D., Duke University Medical Center, Durnham, NC

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