PURPOSE OF THE STUDYBoth the range of motion and load transfer of the sacroiliac (SI) joint improve considerably after lumbar spine surgery. When, following surgery, SI joint pain develops in spite of appropriate physical therapy, injection of an anaesthetic with added corticosteroid into the SI joint is a first choice treatment. The aim of this presentation is to provide information on our experience with this therapy. MATERIAL AND METHODSThirty-four patients after lumbar spine fusion reported lumbalgia different form pain before surgery. In 14 (41%) of them, pain in one of the SI joints was diagnosed as the cause. This group included 12 women and two men at an average age of 56 (range, 47 to 68) years. Ten patients underwent lumbosacral fixation and four had segmental ("floating") lumbar spine fusion. All patients experienced lumbalgia at more than 3 months following surgery, at 8 months on the average (range, 4 to 12 months). None of them had SI joint pain before surgery. The diagnosis was based on specific manoeuvres on physical examination of the joint.Each patient was given an injection of 20 mg (0.5 ml) Methylprednisolone (Depo-Medrol®, Pfizer, Puurs, Belgium) and 4.5 ml 1% Mesocain (Zentiva, Praha, CR).They were inquired as to pain relief 24 h later and then at 1, 3 and 6 months after injection. Subjective feelings were assessed by a visual analogue scale (VAS). The results were analysed using descriptive statistics. RESULTSAll patients reported pain relief within 24 h of injection, but not its complete resolution. The average VAS score before and after the blockage of the SI joint was 9.1 points (8-10) and 4.8 points (2-7), respectively; this implies improvement by an average of 4.3 points (1-6), i.e., approximately by 47.3% (12.5-62.5). The duration of effects varied greatly from patient to patient. The average interval between injection and pain recurrence lasted for 5 weeks (1-28). Most frequently, relief was experienced for 2 weeks, or for 6.8 weeks with the standard deviation included. DISCUSSIONSacroiliac joint dysfunction is a very frequent cause of lumbalgia, particularly after lumbar spine surgery. Physical therapy may not always be effective. SI joint arthrodesis is indicated only in rare cases. One of the few possibilities of pain relief involves intra-articular injection of an anaesthetic with corticosteroid for booster effect. The treatment of SI joint blockage after spinal fusion has recently been dealt with in three reports in the international literature; their conclusions are in accordance with the results of this study. CONCLUSIONSLumbar spine stabilisation surgery may result in overloading the SI joints as the "adjacent segments". An intra-articular injection of anaesthetic can be considered a reliable method for ascertaining the SI joint as the source of a patient's problems. However, even with corticosteroid added, pain relief is not usually long-lasting.
PURPOSE OF THE STUDYThe aim of this prospective study was to report on an open approach to a bony defect of the glenoid associated with anterior shoulder instability, using a modified Latarjet procedure, in elderly patients. MATERIALFrom 2003 to 2005, 11 patients older than 50 years underwent an open Latarjet procedure performed by two senior surgeons. The mean age of the patients was 65 years (range, 51 to 79 years). All of them were available for follow-up examination. There were seven women and four men. The study inclusion criteria were a bony defect of the anterior glenoid confirmed by a CT scan, age over 50 years, and three or more previous dislocations. The mean pre-operative forward elevation was 121.2° ± 16.6° (range, 40° -180°) and external rotation was 43.3° ± 13.1° (range, 5°-80°). The mean number of dislocations before surgery was 4.8 (range, 3 -8). METHODSThe Latarjet operation makes use of a large coracoid bone graft to extend the glenoid articular surface by means of a lengthened bone platform, and a sling effect of the conjoined tendon passing through the subscapularis muscle. The Constant-Murley score was used to evaluate the results. RESULTSShoulder stability and function were restored in all 11 patients at a minimum follow-up of 4 years (range, 49 -69 months). There was no recurrence of instability. The range of motion was minimally reduced; the mean loss of elevation was 18.8°a nd the mean loss of external rotation was 4.0°. The mean Constant-Murley score increased from 56.4 ± 13.3 points preoperatively to 81.8 ± 11.3 points post-operatively (p < 0.05). No significant post-operative complications were observed. DISCUSSIONIt is necessary to differentiate between the Latarjet procedure and its modification popularised by Helfet as the Bristow or the Bristow-Latarjet operation. The Bristow procedure transfers only the tip of the coracoid, along with the attached conjoined tendon, to the anterior side of the neck. This procedure does not treat the bony defect and provides a mere soft-tissue constraint. Only a few reports of the original Latarjet procedure can be found in the international literature. CONCLUSIONSThe open Latarjet reconstruction can successfully restore shoulder stability in joints with a significant bony defect of the glenoid even in elderly patients. It is effective in situations in which soft-tissue reconstruction is not a reasonable option.
Rupture of the anterior cruciate ligament (ACL) is one of the most frequent injuries to the knee joint in the young. ACL repair is a major orthopedic procedure most often performed in the younger adult population. Early stabilization of the knee joint by ACL reconstruction also decreases the risk of injury to other important structures. At ACL reconstruction, the biggest problem is usually the exact placement of drilled tunnels. This significantly affects the outcome of surgery, i. e., range of motion, knee joint stability, reaction of the synovium in the knee, pain, impingement and potential graft failure with lesion development. However, 70 % of ACL reconstructions are carried out by orthopedic surgeons whose experience is limited to less than 20 ACL repair procedures in a year! Arthroscopy does not allow the surgeon to gain a complete 3D view of important anatomical structures, particularly in the anteroposterior direction. Computer-assisted navigation systems should aid in minimizing these problems. First reports on the use of computer-assisted navigation in ACL reconstruction, which have already been published in the international literature, have provided clear evidence that more exact bone tunnel placement can be achieved with navigation than with the use of conventional techniques. In addition, kinematic navigation enables us to measure anteroposterior and rotational knee stability, isometry, impingement and the angles of bone tunnel placement. It permits a choice from various types of graft. Last but not least, kinematic navigation provides a tool for recording surgery outcomes without a necessity to use further examination methods. Its drawbacks, namely, the learning curve, additional fixation of navigation probes to the femur and tibia and slightly longer operative time, should be considered in the context of presumed long-term benefits for the patient.
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