The correlation of supraspinatus outlet view with computed tomography for visualization of the anterior acromial undersurface.

INTRODUCTION: Understanding the real shape of the undersurface of the acromion prior to acromioplasty is indispensable. Today, Supraspinatus outlet view (SSOV) is a standard view used to determine the shape of the anterior acromion. Three types of acromial undersurface were described by Bigliani and Morrison. The purpose of this study was to find out whether the real acromial type can be visualized on X-ray SSOV and compare the shape of the anterior undersurface of the acromion visualized on SSOV, with the shape revealed on 2D CT reconstructions. METHODS: The SSOV X-rays and CT scans of 30 consecutive patients suffering from rotator cuff dysfunction were retrospectively analyzed. The shape of the acromion visualized on plain X-rays was classified according to Bigliani and Morrison classification system. Two-dimensional CT reconstructions were performed, reproducing the lateral, middle, and medial sections of the acromion. The acromial type that was visualized on each of those reconstructions was separately classified according to the Bigliani and Morrison system. A complete profile of the acromial undersurface was constructed from the integration of acromial types seen on each CT section. The acromial morphology seen on X-rays and CTs was compared. RESULTS: A total of 30 patients comprised the study cohort; mean age was 57 (STD = 8.5) years. Three Type I, 22 Type II, and 5 Type III acromions were visualized on the SSOV X-rays. CT reconstructions revealed seven different morphological acromial profiles (I,I,I; I,II,II; I,II,III, etc.), which we divided into 3 groups: (1) Uniform (30%), (2) Internally curved (20%), and (3) Internally hooked (50%). The acromial type visualized on X-ray correlated with the acromial type on at least one CT section in all of the cases. In the case of uniform acromial profile, there is a full correlation between the acromial type visualized on X-rays and the type visualized on CT. In non-uniform profiles, there was an incomplete correlation between the types of the acromion visualized on SSOV and CT. SSOV X-rays correlated with or underestimated, but never overestimated, the acromial morphological type. DISCUSSION: The curved or hooked portion of the acromial undersurface is not always visualized on the SSOV. On X-rays, the middle and lateral sections are seen more accurate than the medial section. CONCLUSION: Surgeons should be aware that SSOV X-rays may underestimate the true type of the acromial undersurface.

Hodgkin Lymphoma Presenting as Severe Shoulder Pain Following Small Quantities of Alcohol Ingestion: A Case Report.

CASE: Shoulder pain is a common symptom. We report a case of a twenty-two-year-old man who had shoulder pain that was induced by small quantities of alcohol ingestion, which is an unusual presenting sign of Hodgkin lymphoma. The history, physical examination of the shoulder, and imaging revealed no noteworthy findings. Chest computed tomography and subsequent biopsy led to the diagnosis of Hodgkin lymphoma. CONCLUSION: This report emphasizes the need to consider Hodgkin lymphoma as part of the differential diagnosis in a patient presenting with shoulder pain that is precipitated by alcohol ingestion.

A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes: a preliminary study.

BACKGROUND: Syndesmotic ankle injuries are not easy to recognize when an associated fracture or frank diastasis is not present. There is a need for a simple, fast, inexpensive, and easily reproducible diagnostic tool to assess the integrity of the distal tibiofibular synedesmosis. HYPOTHESIS: Dynamic ultrasound (US) examination can accurately diagnose anteroinferior tibiofibular ligament (AITFL) rupture. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: We evaluated 3 groups: 9 consecutive professional athletes with recent AITFL rupture, a control group of 18 subjects without a history of ankle injury, and 20 patients with lateral ankle sprain. The dynamic US examination was performed in neutral (N), forced internal rotation (IR), and external rotation (ER) of the foot for measuring the tibiofibular clear space on the anterior aspect of the ankle, at the level of the AITFL, 1 cm proximal to the joint line. RESULTS: The mean age of the study group was 27 years (range, 16-32). Magnetic resonance imaging (MRI) confirmed the diagnosis of AITFL rupture in all cases. Differences between the injured and control group were statistically significant for the N, IR, and ER positions (P < .001) and for the measured Delta between the AITFL in the ER and N positions (P < .01). The difference in the tibiofibular clear space between the 2 ankles of the injured athletes was significantly different compared with the control athletes for all 3 positions (P < .001). The measured difference between the ER and N positions for both sides of the study group showed a specificity and sensitivity of 100% (P < .001; cutoff point of 0.9 mm and 0.7 mm, respectively). The Delta (Delta = ER - N) of the injured side showed a specificity and sensitivity of only 89% (P < .001; cutoff point of 0.4 mm). Additionally, the third group with the history of lateral ankle sprain showed, as expected, that this type of injury does not correlate with AITFL injury on dynamic US examination. CONCLUSION: We conclude that dynamic US examination can be used to accurately diagnose an AITFL rupture. This preliminary study has found the described method to be a simple, inexpensive, and easily reproducible examination.

[Deep vein thrombosis and thromboembolism in arthroscopic surgery].

UNLABELLED: Thromboembolic events that occur after routine arthroscopic surgery comprise a complication which may carry lethal consequences. The occurrence of this complication after arthroscopic surgery raises the question as to whether prophylactic anticoagulation should be instituted in these procedures. This review aimed to verify, by a literature search, if routine antithrombotic prophylaxis is justified in arthroscopic surgery. With this in mind, the literature concerning arthroscopic surgery, deep vein thrombosis (DVT) and thrombo-embolism was searched using the available literature concerning these fields, and reviewing the computerized literature database in these fields dating back 30 years. Our review shows that clinically significant thromboembolic events are extremely rare in arthroscopic surgery and may occur in between 1:2000 to 1:5000 cases. Incidence of DVT is higher, detected in prospective studies using venography or Doppler ultrasound in 0.6% to 18%, while the majority of the literature quotes an occurrence of 5% to 10%. Retrospective studies, based on clinically evident DVT, show an incidence of about 1:1000. Approximately 1:10 of DVT cases occur in the proximal venous tree, comprising a potential source for thromboembolic events. Anticoagulants entail certain complications, with an incidence of up to 8%, a far higher incidence than the risk of clinically evident thromboembolic events. CONCLUSIONS: The occurrence of a clinically apparent thromboembolic event in arthroscopic surgery is extremely rare and probably does not justify the risk of prophylactic antithrombotic medication. As a rule, patients should be instructed for early mobilization as the sole preventive method. If evident risk factors are present: old age, obesity, congestive heart failure (CHF), malignancy, varicose veins, past vein surgery or chronic lower limb swelling--prophylactic treatment should be considered. In such cases certain authorities would recommend administration of aspirin alone. In patients who suffered previous thromboembolic events, further prophylactic measures should be instituted, inclusive of antithrombotic agents as practiced in other orthopaedic procedures.

Avulsion of the distal biceps brachii tendon in middle-aged population: is surgical repair advisable? A comparative study of 22 patients treated with either nonoperative management or early anatomical repair.

INTRODUCTION: Operative anatomical repair following complete avulsion of the distal biceps brachii tendon in athletic population is usually recommended. However, there is no clear consensus as to the advisability of the operation in middle-aged population. We therefore undertook a study to examine whether early anatomical repair in this specific population is preferable to nonoperative management. PATIENTS AND METHODS: We evaluated the outcome at a mean of 2 years following this injury in a group of 22 middle-aged active men. Of this group, 12 were managed with early anatomical repair and 10 were managed nonoperatively. Our evaluation included subjective functional outcome scales, isokinetic measurements, and postoperative complication survey. RESULTS: Although subjective functional assessment demonstrated higher satisfaction in the operated group (p<.05), 9 of the 10 nonoperated patients reported good to excellent outcome as well. Isokinetic evaluation revealed higher performance of elbow flexors and forearm supinators in the group managed operatively (p<.05), while two patients in this group suffered nerve injuries, though both resolved eventually. DISCUSSION AND CONCLUSIONS: Surgical repair of complete avulsion of the distal biceps brachii tendon in middle-aged active population may be advised to patients, as it achieves superior outcome both subjectively and objectively. However, nonoperative management should be seriously discussed with each patient, as it is expected to result in good to excellent outcome as well, while avoiding potential complications related to the surgery.

A simple method for quantitative evaluation of the missing area of the anterior glenoid in anterior instability of the glenohumeral joint.

OBJECTIVE: The objective of this study was to describe and validate a simple method to quantitatively calculate the missing area of the anterior part of the glenoid in anterior glenohumeral instability. MATERIALS AND METHODS: The calculations were developed from three-dimensional (3D)-reconstructed computerized tomography en face images of the glenoid with "subtraction" of the humeral head in 13 consecutive cases with known anterior glenohumeral joint instability diagnosed by history and clinical examination. The inferior portion of the glenoid was approximated to a true circle whose center was determined by means of a femoral head gauge. The eroded anterior area was calculated as the ratio between the depth (a perpendicular line from the center of the circle to the eroded edge of the anterior glenoid) and the radius of the inferior glenoid circle. This data was then compared to the results obtained by two additional different methods: direct computerized measurements of the missing area and direct computerized measurement of the ratio between the radius and depth, on two dimensional computed tomography (CT) en face view reconstructions of the glenoid. RESULTS: We provide a function that correlates the ratio between depth and radius of the inferior glenoid circle and the area of the missing anterior glenoid. The results obtained by three different methods were comparable. Simple trigonometric calculations showed that a 5% area defect corresponds to 0.8 (12.5%) of the radius of the inferior glenoid, while a 20% area defect corresponds to 0.5 (50%) of the same radius (Table 1). Table 1 Results according to each different method Patient Sex Side CA1 MA1 PAM1 R2 D2 PAM2 R3 D3 PAM3 1 M R 738 19.1 2.58 15.1 13.4 2.45 16 14 2.6 2 M R 462.6 30.5 6.59 11.9 9.7 4.83 16 10 12.97 3 F L 359 24.5 6.82 17 11.8 9.86 11.8 17 9.86 4 M L 522 59.4 11.37 12.7 9.1 8.95 16 10 12.97 5 M L 670 93.1 13.89 13.6 7.6 16.84 16 9 16.31 6 M R 659 137.5 20.8 14.3 7.1 20.10 20 8 25.23 7 M L 520 137 26.34 11.6 5.1 23.49 16 8 19.55 AVG 12.63 12.36 14.21 SD 8.46 7.92 7.20 CA1 Area of circle directly measured by MPR software, MA1 missing area of circle measured by MPR software, PAM1 calculated (100 x MA1/CA1) percentage area missing for method 1, R2 radius of the circle measured by MPR software, D2 depth from the missing edge to the center of the circle measured by MPR software, PAM2 calculated Percentage area missing from R2 and D2 using the function "q" (Appendix), R3 radius of the circle measured with a femoral gauge, D3 depth from the missing edge to the center of the circle measured with a femoral gauge, PAM3 calculated Percentage area missing from R3 and D3 using the function "q" (Appendix), AVG average, SD standard deviation CONCLUSION: Using this simple method and the function provided, the eroded area of the anterior part of the glenoid in anterior glenohumeral instability can be calculated preoperatively using a 3D CT reconstruction of the glenoid with "subtraction" of the humeral head, obviating the need for sophisticated software to obtain this critical information for preoperative decision making.

Iatrogenic forearm compartment syndrome in a cardiac intensive care unit induced by brachial artery puncture and acute anticoagulation.

A previously healthy patient developed late compartment syndrome in the cardiac intensive care unit after a brachial artery puncture due to acute heparinization after successful percutaneous transluminal coronary angioplasty (PTCA) and stent implantation. The cardiologists recognized the problem and immediately consulted an orthopedic surgeon, who promptly performed surgery. The latter consisted of decompression and fasciotomy. The patient recovered excellent hand function without any neurologic or muscular deficits. Knowledge and understanding of the clinical aspects of this complication are crucial in this devastating syndrome.