Doppler sonography in the diagnosis of round ligament varicosities during pregnancy

Round ligament varicosities during pregnancy are an important differential diagnosis of complicated inguinal hernias and have been reported only rarely. Diagnosis is reassuring and may prevent unnecessary surgical exploration. We describe a case of round ligament varicosities presenting during pregnancy that was readily diagnosed with Doppler sonography.     

关节镜下修复交叉韧带损伤术后康复训练对患肢功能恢复的影响

目的 探讨在关节镜下同种异体肌腱重建交叉韧带并直视修复内侧副韧带手术后康复训练的效果.方法 将90例膝关节内侧副韧带、前后交叉韧带联合损伤患者随机分为康复组及对照组,各45例.2组患者均在关节镜下行同种异体肌腱重建交叉韧带并直视修复内侧副韧带术.对照组患者术后行常规康复训练.康复组患者在术前进行心理及康复训练指导,术后早期即指导患者开始系统功能锻练.术后3个月评定疗效.结果 康复组术后膝关节功能优良率为93.3%,对照组为77.7%.二者比较有统计学意义(χ2＝4.41,P<0.05),康复组优于对照组.结论 关节镜是精细而复杂的手术,正确的术前皮肤准备、术前术后的心理准备和术后康复训练是确保手术成功及膝关节功能恢复的重要保证.     

Seconds from disaster: lessons learned from laparoscopic release of the median arcuate ligament

Median arcuate ligament syndrome (MALS) is a rare entity that manifests as abdominal pain, nausea, vomiting, and diarrhea. The median arcuate ligament is a fibrous band that connects the crura of the diaphragm. In some people, the ligament is positioned in a way that compresses the celiac axis, which in a subset of individuals causes the symptoms associated with MALS. Surgical release of the ligament can relieve these symptoms. After viewing a video that described the laparoscopic median arcuate ligament release technique at the 2006 SAGES meeting and reviewing the online video, we report our experience with two cases and discuss the lessons learned in performing the procedure within a training program. We also discuss the extent to which surgical resident participation contributes to intraoperative complications during a new and complex surgery. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Comparative study of knee anterior cruciate ligament reconstruction with or without fluoroscopic assistance: a prospective study of 73 cases

INTRODUCTION: Correct placement of both tibial and femoral tunnels is one of the main factors for a favorable clinical outcome after anterior cruciate ligament (ACL) reconstruction. We used an original system of computer assisted surgery (CAS). The system, based on fluoroscopic guidance combined with special graphical software of image analyzing, showed to the surgeon, before drilling, the recommended placement of tibial and femoral tunnel centers. We compared the first anatomical and clinical results of this procedure to the usual one single incision technique. MATERIALS AND METHODS: We conducted a prospective study on 73 patients; 37 patients were operated on with CAS and 36 without CAS, by the same senior surgeon. The mean age was 27 years for both groups. Every patient was reviewed at an average of 2.2 years (range 1-4.5) by an independent observer, using IKDC scoring system, KT-1000, and passive stress radiographs. RESULTS: Time between ACL rupture and reconstruction averaged 30 months for both groups. CAS needed 9.3 min extra surgery time. Clinical evaluation was graded from A to C as per the IKDC scoring system: 67.6% A, 29.7% B, 2.7% C with CAS; and 60% A, 37.1% B, 2.9% C without CAS. IKDC subjective knee evaluation score averaged 89.7 with CAS and 89.5 without CAS. Pre operative KT-1000 maxi manual differential laxity averaged 7. At revision time, all the patients after CAS had a differential laxity less than 2 and 97.7% without CAS. Stress X-rays differential laxity averaged 2.4 mm with CAS and 3 mm without CAS. The area of dispersion of the tunnels' center was smaller on the femoral side using the CAS method. There was no statistically significant difference between both groups using IKDC score, KT-1000 and passive stress radiographs. CONCLUSIONS: The CAS method provided a more accurate and reproducible tunnels placement without clinical significant effect.     

Assessment of Rotational Instability with Disruption of the Accessory Collateral Ligament of the Thumb MCP Joint: A Biomechanical Study

OBJECTIVES: The objective of this paper was to biomechanically investigate rotational stability of the thumb after ulnar collateral ligament (UCL) and accessory collateral ligament (ACL) disruption and repair at the metacarpal joint of the thumb. METHODS: Twelve fresh frozen adult cadaveric thumbs were used. The torsion test was performed under constant rotation of 1/s through 30 arc of metacarpal phalangeal (MCP) joint. The torsional resistance was determined for four categories: first no intervention of the UCL structures (control), next with the proper UCL cut at the distal insertion, then with the additional ACL ligament cut, and lastly with the repair of only the proper UCL. The decrease on the amount of torsional rigidity for each of the last three categories was determined and compared. Each thumb was used as its own control. Significance of the differences in each test categories was statistically determined. RESULTS: After the proper UCL was cut, the torsional rigidity of the MCP joint was reduced 35.18 +/- 17.56% (p < 0.001). When, additionally, the ACL was cut, the torsional rigidity of the MCP joint was further reduced to 49.34 +/- 16.82% (P < 0.001). After repair of only the proper UCL, the torsional rigidity of the MCP joint improved, but still showed a considerable reduction from controls. The amount of reduction was not consistent among specimens and was 13.52 +/- 16.40%. CONCLUSIONS: The ACL ligament is a contributor of rotary stability as well as a provider of lateral stability. Leaving the ruptured ACL unrepaired causes some residual rotating instability and that may lead to future rotational instability of the MCP joint.     

不同手术方法治疗胫骨髁间棘撕脱骨折的临床疗效分析

目的 观察不同手术方法治疗胫骨髁间棘撕脱骨折的疗效.方法 1995年10月至2005年10月应用3种手术方法治疗胫骨髁间棘撕脱骨折患者49例:切开复位内固定17例(A组);关节镜下复位内固定19例(B组);有限切开加关节镜辅助复位内固定13例(C组).平均随访时间4.6年.结果 A、B、C 3组伸膝功能正常分别为35.5%、16.O%和38.0%;轻度异常分别为35.5%、11.0%和23.0%;中度异常29.0%、47.0%和31.0%;重度异常0、26.0%和8.0%.3组屈膝正常分别为82.0%、78.0%和84.0%;轻度异常12.0%、11.0%和8.0%;中度异常6.0%、11.0%和8.0%.Laehman和前抽屉试验阳性率3组分别为35.0%、45.0%和38.0%,轴移试验阳性率3组分别为11.0%、16.O%和13.0%.Lysholm 评分3组平均分别为98.6分、97.3分和98.2分;Tegner评分分别为6.6分、6.4分和6.7分,KT-2000检查胫骨前移分别平均为6.9 mm、7.1 mm和6.6 mm;健患侧对比差异分别平均为1.4 mm、1.7 mm和1.5 mm,除伸膝功能A组与B组比较差异有统计学意义外(P=0.02,P＜0.05),其他各种指标组间比较均无显著统计学意义(P＞0.05).结论 有限切开辅助关节镜下适当的过度复位和三维、坚强内固定是治疗胫骨髁间棘撕脱骨折较为理想的方法.     

自体腘绳肌腱单、双束重建前交叉韧带临床比较研究

目的 比较自体腘绳肌腱单、双束重建前交叉韧带的临床效果.方法 2005年5月至12月采用双束重建前交叉韧带患者33例(双束组),单束重建患者41例(单束组),均采用自体半腱肌腱和股薄肌腱.双束组4例失访,随访时间14～22个月,平均18个月;单束组8例失访,随访时间14-21个月,平均18个月.采用国际膝关节评分委员会评分标准(IKDC),Lysholm和Tegner评分、KT-2000及Biodex肌力测试评价.结果 双束组IKDC,Lysholm和Tegner评分分别由术前的60、66、4分显著上升至术后的85、94、6分.KT-2000在134 N下30°和90°位移情况由术前的5.8和2.4 mm减少为术后1.2和1.1 mm(P＜0.01).双束组伤侧膝关节伸膝及屈膝的峰力矩在60°/s下,相对于正常侧分别为81%和87%,120°/s下为76%和85%.各项值均显著低于对侧(P＜0.01).尽管在30°位KT-2000测量值和伸膝肌力的恢复方面,双束重建较单束重建表现出了更好的趋势,但功能评分,KT测量值和BIODEX测量的结果,单、双束组差异无统计学意义.结论 自体胭绳肌腱单、双束重建前交叉韧带均可以恢复膝关节稳定,改善关节功能,双束重建患者在30°位前后稳定性和伸膝肌力方面表现出了较单束重建更好的趋势.     

The effect of medial collateral ligament repair tension on elbow joint kinematics and stability

PURPOSE: Medial collateral ligament (MCL) repair is commonly performed for the management of acute or subacute instability after elbow dislocations and fracture-dislocations. The effectiveness of transosseous repair of the MCL, as is typically performed clinically, in restoring the normal kinematics and stability of the elbow is of interest as is the effect of MCL tensioning on the initial stability of the elbow. The purpose of this study was to determine whether suture repair of the MCL is able to restore the normal kinematics and stability of the elbow and to determine the optimal initial MCL repair tension. METHODS: Six cadaveric upper extremities were mounted in an upper limb joint simulator. Simulated active and passive elbow flexion was generated while the kinematics were measured with the arm in the dependent and the valgus gravity-loaded orientations. After testing the intact elbow, the MCL was released at its humeral attachment and repaired using a transosseous suture technique at three different repair tensions: 20, 40, and 60 N. RESULTS: Medial collateral ligament repair using a transosseous suture technique restored the kinematics and stability of the MCL-deficient elbow. Motion pathways were affected by the magnitude of initial MCL tension. For all arm orientations and forearm positions, the 20-N and 40-N repairs were not statistically different from each other or from the intact MCL. The 60-N repairs, however, were often statistically different than the other groups, suggesting an overtightening that tended to pull the ulna into a varus position-especially in the midrange of flexion. CONCLUSIONS: These data suggest that MCL repair using transosseous sutures provide adequate joint stability to permit early motion. There is a broad range of acceptable tensions for MCL repair, which is a favorable, clinically relevant finding. Clinical studies are needed to validate these in vitro results.     

The effect of the annular ligament on kinematics of the radial head

PURPOSE: There is evidence that the radial head translates during pronation and supination. This study measured radial head movement and the location of the pronation-supination axis of the forearm with and without the annular ligament. METHODS: Thirteen cadaveric arms were attached to a custom-built frame. Pronation and supination were achieved by actuation of the pronator teres and biceps tendons, respectively. Motion was captured by video cameras via marker arrays attached to the distal radius, distal ulna, humerus, and radial head. Three pronation-supination trials were performed with the annular ligament intact and the elbow positioned at 90 degrees . The sequence was repeated after transection of the annular ligament. RESULTS: The radial head traveled an average of 2.1 mm in the anteroposterior direction and 1.6 mm in the mediolateral direction during forearm rotation. After annular ligament resection, travel of the radial head increased by an average of 44% in the mediolateral direction and by 24% in the anteroposterior direction. On average, the mean pronation-supination axis (screw displacement axis) passed 1.4 mm +/- 1.9 medial to the center of the capitellum and through the center of the ulnar head. Loss of the annular ligament did not change the location of the pronation-supination axis. CONCLUSIONS: During forearm rotation, the radial head travels to a greater extent in the anteroposterior direction than in the mediolateral direction. Loss of the stabilizing effect of the annular ligament increases the travel mediolaterally more than anteroposteriorly. The pronation-supination axis of the forearm is nearly constant and is not affected by annular ligament transection.