Objectives

This study aimed to investigate time-dependent gene expression of injured human anterior cruciate ligament (ACL), and to evaluate the histological changes of the ACL remnant in terms of cellular characterisation.

Purpose: Since the pathomechanism of patellofemoral malalignment is complex, multifactorial and varies individually, the ideal treatment has been a matter of controversy. The purpose of this study was to demonstrate the clinical outcome and radiographic changes of knees with patellofemoral malalignment treated with Fulkerson osteotomy after a minimum follow-up of 24 months.

Materials and Methods: Sixty knees in 40 patients (32 female and 8 male) were examined with a mean of 55 20 (25 97) months after having undergone medialization of the tibial tubercle using Fulkerson osteotomy for patel-lofemoral malalignment. Mean age at surgery was 20 7 (12 42) years. Prior surgery of medial retinacular plication in 4 knees and lateral retinacular release in 1 knee had been performed. During surgery, amount of tibial tubercle transfer was determined by examining the patellar tracking over full range of knee motion. After Fulkerson osteotomy, proximal realignment procedures were added depending on arthroscopic appearance of the patellofemoral adaptation. The clinical outcome was evaluated using Fulkersons knee instability scale. The radiographic parameters including congruence angle, lateral patellofemoral angle, tilting angle and lateral shift ratio were measured in Merchant view.

Results: Mean distance of medial transfer of tibial tubercle was 12.8 3.1 (8 22) mm. Lateral retinacular release in 54 knees and adductor magnus tenodesis (Avikainen procedure) in 2 knees were simultaneously performed combined with Fulkerson osteotomy. All radiographic parameters at the final follow-up were significantly improved compared to the preoperative values (p < 0.05 in a paired t-test), that is, from 23.0 14.6 to 0.4 13.7 degrees in congruence angle, from −6.3 9.0 to 0.4 6.9 degrees in lateral patellofemoral angle, from 25.1 11.5 to 16.3 5.6 degrees in tilting angle and from 35 24 to 17 9% in lateral shift ratio. Mean score in Fulkersons knee instability scale was 96 5 points at the final follow-up. All knees except 3 were ranked as excellent, very good or good. Two knees with moderate osteoarthritis of the patellofemoral joint were ranked as fair. One knee that had postoperative recurrence of patellar subluxation underwent a revision surgery with Avikainen procedure.

Discussion: In the clinical study with a minimum 2-year follow-up, Fulkerson tibial tubercle osteotomy provided excellent or good overall outcome in 93% of patients in combination with proximal realignment surgeries. Although all radiographic parameters were significantly improved, it was found that the lateral shift of the patella was more effectively corrected compared to the lateral tilt. It was suggested that reconstruction of the medial patellofemoral structures might be more suitable than Fulkerson osteotomy for some knees characterized by significant lateral tilt.

The purpose of this study is to introduce our technique of free hand screw insertion for scaphoid fractures and clarify the indications of this procedure.

From 1988 to date, we performed this method in 86 cases (75 males and 11 females). Ages ranged from 11 to 73 years (av.: 29). There were 24 cases of acute stable type, 46 of acute unstable and 16 of delayed fibrous union. Screws used were original Herbert screws in 48, other cannulated type screws in 38.

Using an image intensifier, from a small skin incision over the scaphotrapezium joint, a Kirschner wire is inserted to stabilize the fracture temporarily. The wire is pulled volarward to rotate the scaphoid and a second wire is inserted along the intended line of the screw. With the original Herbert screw, after removing the wire, the screw is inserted free-hand. With the other cannulated screws, the second wire is used as guide pin.

Results of 82 cases with follow-up times over 6 months were reviewed. In one case, bony fusion was achieved but revealed symptomatic malunion. In two cases, bony fusion was not achieved. In one of them, an additional bone graft was performed, and good bony union was achieved. In the remaining 79 cases, good bony fusion and good clinical results were achieved.

The best indication for this method is an acute unstable fracture. For acute stable fractures, we recommend this method for three types of patients: those who cannot accept long term immobilization, those who desire to return to athletic activities as soon as possible, and those who also have another fracture in the forearm. It can also be used in cases of delayed fibrous union when good alignment can be achieved and a bone graft is unnecessary.

Vascularized bone grafts (VFG) have brought great benefits in the field of reconstruction of the lower extremity. However, complications such as fracture of the grafted fibula and delayed union are sometimes seen. Not only to prevent these complications but also for stability after fracture of the grafted fibula, the Ilizarov external fixator is a very useful option. We report here the clinical results of cases treated by VFG combined with Ilizarov external fixator for reconstruction of the lower extremity.

We have performed 53 vascularized fibula transfers to reconstruct lower extremities. An Ilizarov external fixator was used for the initial immobilization in 7 (2 femur, 5 tibia) and for delayed union or fracture of the grafted fibula in 2 cases of congenital pseudoarthrosis of the tibia.

All patients achieved good bone reconstruction. All are able to walk without a brace except for one congenital case. The average period to achieve bony fusion was 13 months in femur cases, 6 months in adult tibia cases and 2 months in congenital cases. The average periods to walk without a brace were 14 months, 8 months and 10 months respectively. However, it took 9 months and 28 months to achieve bony union in the cases with delayed union or fracture of the grafted fibula.

In the reconstruction of the lower extremities using VFG, the determining factor in method selection is whether sufficient mechanical support is available. An Ilizarov external fixator for immobilization permits the patient to walk as soon as possible. Dynamization from this semi-rigid external fixator causes bone hypertrophy and improved incorporation of the graft.