Abstracts from Current Literature

Abstract

S OF CURRENT LITERATURE Paessler HH; Mastrokalos DS Anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons, bone patellar tendon, or quadriceps tendon-graft with press-fit fixation without hardware. A new and innovative procedure. Orthop Clin North Am 2003 Jan; 34(1):49-64 BONE--PATELLAR TENDON: The "no hardware" technique for ACL reconstruction is a new method that offers many advantages and is straightforward to perform. Its main innovative feature is that it does not require boneblock harvesting from the patella. This reduces donor site morbidity and prevents patellar fractures. The bone tunnels are made using tube harvesters and compaction drilling. This minimizes traumaand obviates the risk of bone necrosis. The articular entrance of the tibial tunnel is completely occupied by the grafts. This prevents a windshield-wiper effect and synovial fluid ingress into the tunnel, and enhances graft incorporation. The fact that no hardware is used with both patellar tendon or hamstring grafts significantly reduces the overall cost of the operation and facilitates revision surgery. The quadriceps tendon is also a very good graft. It is thick and has good biomechanical properties and low donor site morbidity. Its disadvantages are: weakness of quadriceps after the operation, an unsightly scar, and some difficulty in graft harvesting [58]. Also, postoperative MRI is not fraught with the problem of metal artifacts. It is difficult to decide which of the methods currently available for ACL reconstruction is the best because most of them give satisfactory results. In the future, assessments of knee ligament reconstruction techniques should look at long-term stability combined with low complication rates. Ease of revision surgery and low cost should also be taken into consideration, given the large annual volume of knee ligament reconstructions (50,000 in the United States alone) [59]. We believe that our technique addresses most of these issues, and that it constitutes a useful alternative method for ACL reconstruction. SEMITENDINOSUS--GRACILIS: This technique, which was used with 915 patients from June 1998 to February 2002, shows a particularly low rate of postoperative morbidity. The reason is probably to be found in the "waterproofing" of the bone tunnels, which lead to less postoperative bleeding and swelling. No drains were used. Rehabilitation follows the same protocol as used for the reconstruction using patellar tendon grafts (accelerated/functional). As expected, there was no widening of the femoral tunnels and little widening of the tibial tunnels. Interestingly, tibial tunnel enlargement was significantly less in a nonaccelarated rehabilitation group than in the accelerated group [60] without affecting stability. The measured internal torque of the hamstrings, as well as their flexion force, already had returned to normal 12 months postoperatively. In a prospective randomized (unpublished) study comparing this technique with ACL reconstruction with BPT grafts with medial or lateral third with only one bone plug (from the tibial tuberosity, see technique described above), we found no significant difference between both groups in subjective scores, stability, KT-1000 values, Tegner activity score, and IKDC at 1-year follow-up. Only the results of kneeling and knee walking testing were significantly better in the hamstring group [61]. In summary, the advantages of this presented technique are: (1) the knot of the graft is close proximally to the anatomic site of the insertion of the ACL, thus avoiding the Bungee effect.; (2) the press-fit tunnel fixation prevents synovial fluid entering the bone tunnels, windshield-wiper effect, and longitudinal motion within the tunnel; the intensive contact between the bony wall of the tunnel and graft collagen over a long distance without any suture material results in quick and complete graft incorporation; and (3) no fixation material means no hardware problems, facilitates revision surgery, and lowers overall costs. 176 / The Journal of Manual & Manipulative Therapy, 2003 The Journal of Manual & Manipulative Therapy Vol. 11 No. 3 (2003), 176 177 Kalainov DM; Hartigan BJ Bicycling-induced ulnar tunnel syndrome. Am J Orthop 2003 Apr;32(4): 210-1 Symptoms of ulnar tunnel syndrome are commonly experienced by avid bicyclists. Previous orthopedic and hand surgery publications have rarely included bicycling as a causative factor for this condition. We present the case of a 41-year-old man who developed bilateral ulnar tunnel syndrome during a week-long mountain bicycling tour. His symptoms gradually improved with nonoperative treatment measures, including rest, splinting, and nonsteroidal anti-inflammatory medication. Kim DH; Silber JS; Albert TJ Osteoporotic vertebral compression fractures. Instr Course Lect 2003; 52: 541-50 Osteoporotic vertebral compression fractures are a commonly encountered clinical problem. Although the majority of patients with this injury experience a benign and self-limited course of gradually resolving pain, a significant number continue to experience chronic pain and disability. In evaluating a patient with a vertebral compression fracture, the differential diagnosis must consider not only osteoporosis, but also various causes of osteomalacia, endocrinopathy, and malignancy. Accumulation of multiple compression fractures and increased thoracolumbar kyphosis are associated with a poor prognosis. Multiple medical treatments--including hormone replacement therapy, calcitonin, and bisphosphonates--are effective in maintaining or increasing bone mass and reducing the risk of compression fracture. Conventional treatment in the form of pain medication, activity-limitation, and occasionally bracing is effective in returning most patients to their previous level of functioning. When therapies fail, patients may be considered for minimally invasive treatments such as vertebroplasty or kyphoplasty. Surgery, although enormously challenging because of poor underlying health status and structurally weak bone, may be the last resort for a small percentage of patients experiencing progressive deformity or neurologic deficit. Riew KD; McCulloch JA; Delamarter RB; Microsurgery for degenerative conditions of the cervical spine. Instr Course Lect 2003; 52: 497-508 Although the operating microscope has been used for spine surgery for more than 20 years, its use is still not widely accepted by orthopaedic spine surgeons. Nevertheless, surgeons who have used the operating microscope are well aware of its many advantages in performing spine surgery. Most notably, the superior visualization it provides allows for faster, safer, and more extensive decompressions. The reluctance of many surgeons to use the operating microscope often has to do with trepidation regarding new technology. The use of the operating microscope when performing anterior and posterior cervical spine surgery makes these procedures easier to carry out and decreases the risk of complications during decompression of the spinal cord. Smith PN; Knaub MA; Kang JD Anterior cervical approaches for cervical radiculopathy and myelopathy. Instr Course Lect 2003; 52: 455-63 Compression of the spinal cord and nerve roots caused by spondylotic changes or disk herniations is the most common etiology for cervical myelopathy, radiculopathy, or myeloradiculopathy. Surgical intervention in treating these conditions has been very successful. Anterior approaches to the cervical spine are being used for the treatment of cervical radiculopathy and myelopathy. The technical spects of anterior diskectomy and corpectomy, methods of fusion, and the use of instrumentation are important treatment considerations. ABSTRACTS OF CURRENT LITERATURE / 177S OF CURRENT LITERATURE / 177