Surgical treatment of full-thickness rotator cuff tears in patients 40 years of age or younger.

Full-thickness tears of the rotator cuff are uncommon in the first 4 decades of life. A retrospective analysis was conducted of 19 consecutive patients who were 40 years of age or younger and had been treated surgically for a full-thickness tear of the rotator cuff. Sixteen patients (84%) recalled an acute injury that heralded the onset of symptoms. Five of the patients had sustained an initial glenohumeral dislocation. At an average follow-up of 5.7 years, all patients were evaluated with regard to pain, function, range of motion, strength, return-to-work status, return-to-sport status, and overall postoperative satisfaction. After operation, 15 patients (79%) reported diminished pain relative to their preoperative level, and 12 (63%) of 19 were able to function with the extremity above shoulder level. Fourteen patients (74%) returned to full-time employment, and half returned to sporting activities. Thirteen patients (68%) reported subjective improvement with regard to daily functional activities after surgical intervention. The most favorable results were seen in those patients who had sustained an acute glenohumeral dislocation in conjunction with a full-thickness rotator cuff tear and underwent combined stabilization and repair. The outcome for patients who received worker's compensation was less favorable.

Treatment of symptomatic glenoid loosening following unconstrained shoulder arthroplasty.

Nine patients with symptomatic glenoid loosening were identified and ultimately underwent surgical revision. Preoperative assessment demonstrated that pain, decreased range of motion, and functional disability were common features. A painful clunking sensation with forward elevation of the arm was noted in four of the nine patients. At surgical revision, a grossly loose glenoid component was found in all cases and removed. Seven of the nine patients underwent revision using another cemented glenoid component, and two patients were left with a hemiarthroplasty due to glenoid bone deficiency. Results following revision surgery demonstrated increased range of motion, decreased pain, and increased functional ability with good overall patient satisfaction in seven of nine patients. Two patients in whom revision glenoid components were implanted were considered failures due to recurrent loosening. Although revision of the glenoid component is often technically feasible, recurrent loosening may occur. Revision to a hemiarthroplasty may be an acceptable alternative to glenoid replacement.

Intraosseous patellar blood supply after medial parapatellar arthrotomy.

Total knee arthroplasty surgical exposure compromises blood flow to the patella. This reduction in blood flow may result in numerous patellar related complications. This study examined the intraosseous blood supply in normal patellas and those simulating total knee arthroplasty exposure. Fifteen anatomic specimen patellas were used. Ten undisturbed patellas were injected intravascularly with a colored perfusate via at least one geniculate artery, and five were subjected to a median parapatellar approach and a lateral release before injecting. Every patella was removed, embedded in epoxy, and sequentially milled. An orthogonal grid was used to position evident interosseous vessels, and each grid was normalized, allowing comparison among patellas. Perfused intrapatellar arteries formed an anastomotic network of penetrating and radiating arteries. Eighty percent of the interosseous blood supply was found in the central 50% of the undisturbed patellas. The surgically exposed patellas incurred a 75% decrease in total perfusion. There was no significant inflow from the periphery of the patella because the entire blood supply appeared to come from the anterior cortical perforating vessels. Damage to the central 50% of interosseous bone or anterior soft tissue cuff because of a central fixation post or anterior cruciate ligament graft increases the risk for segmental devascularization.

Formation of structural grafts from cancellous bone fragments.

Autogenous cancellous bone fragments can be compressed rapidly during surgery to create reproducible load-bearing grafts. Of the 32 grafts tested, 10 were constructed of composite cortical-cancellous bovine bone and 22 of cancellous human bone. Compressed composite bovine grafts and compressed human cancellous grafts supported average axial compressive loads of 2148 N and 960 N, respectively. Compared to iliac crest grafts, compression grafts may have better load-bearing capabilities and greater reproducibility. Potential applications include trauma, delayed unions, arthrodesis, and spinal fusions.

Cine magnetic resonance imaging of the subcoracoid region.

Cine magnetic resonance imaging (MRI) was used to define the normal space between the humeral head and coracoid process, known as the subcoracoid space, to quantify the subcoracoid space in symptomatic patients and identify the anatomic structures responsible for narrowing of this space. The study population was comprised of 50 normal volunteers and 75 patients with shoulder pain. All subjects underwent cine MRI of the shoulder using a shoulder-rotating device that allows progressive rotation of the glenohumeral joint in 10 degrees increments from internal to external rotation while scanning the shoulder in the axial plane. In asymptomatic patients, the normal interval between the lesser tuberosity and coracoid process (coracohumeral distance) averaged 11 mm in maximum internal rotation. In symptomatic patients, impingement or entrapment of the subscapularis tendon and other soft-tissue structures between the lesser tuberosity and the coracoid process in internal rotation was identified, and the mean distance between the lesser tuberosity and coracoid process measured 5.5 mm in maximum internal rotation. This new MRI technique for shoulder imaging is safe, easy to perform, noninvasive, and well-tolerated by patients. Cine MRI provides valuable information on the subcoracoid region not obtainable with other methods.

Treatment of a knee contracture using a knee orthosis incorporating stress-relaxation techniques.

The subject of this case report was a 67-year-old Caucasian woman who had undergone total knee arthroplasty of the right knee. Postoperative physical therapy and a new orthosis that utilizes principles of stress relaxation (constant displacement) and static progressive stretching were used to reestablish range of motion. The total treatment time (cumulative orthosis wear time) was 32.5 hours over a period of 29 days, and the patient obtained a 17-degree increase in active range of motion. Six months later there was no measurable loss in range of motion. The results of the treatment may be beneficial for some patients. Researchers and clinicians need to conduct studies to further evaluate this approach to knee contracture management.

Static progressive stretch to reestablish elbow range of motion.

Static progressive stretch (SPS) is a technique using the biomechanical principle of stress relaxation to restore range of motion (ROM) in joint contractures. Existing techniques such as dynamic splinting and traction rely on a time-dependent material property, creep, which applies a continuous load. Other techniques, such as serial casting and static splinting, are time intensive and usually require assistance by a therapist. This study evaluates SPS via a new orthosis that directly applies SPS incrementally through patient-controlled therapy, allowing for stress relaxation of contracted tissue. Patients used the device in 30-minute treatment protocols. The length of treatment time varied between one and three months. Twenty patients with elbow contractures who had limited success with other treatment modalities including serial casting, dynamic splinting, physical therapy, and/or surgery, underwent SPS using the new orthosis. The increase in motion for the 20 patients in the study averaged 31 degrees (69%). All patients expressed satisfaction, with no complications and no deterioration in ROM at the one-year follow-up evaluation.

Kinematic MRI of the shoulder.

OBJECTIVE: Clinical evaluation of shoulder pain can be difficult. Pain in the shoulder is often dynamic/positional, and it can often be elicited only during specific activity or function. Soft tissue deforms or changes in shape through motion. These complex interrelationships at the glenoid humeral joint require dynamic studies to accurately evaluate normal anatomy and abnormal pathology. The objective of our study was to evaluate the use of a dynamic cyclic cine imaging to evaluate the glenoid humeral joint. MATERIALS AND METHODS: Kinematic MRI was performed using axial 5 mm sections of the gradient echo and dedicated shoulder surface coil. The patient's arm was placed in the Bonutti cine shoulder system and allowed fixed incremental rotational movement of the shoulder at 10 degrees intervals. Images were reformatted onto a dynamic cine motion by oscillating from internal to external rotation then back to internal rotation. A total of 24 asymptomatic shoulders and 35 symptomatic painful shoulders were studied. RESULTS: Normal variations in the glenoid labrum were readily identified. The glenoid labrum in external rotation is taunt and triangular with well-identified capsular attachments. In neutral rotation the labrum often has increased signal and the middle glenoid humeral ligament occasionally blends with the labrum, making identification difficult. In maximum internal rotation the labrum is rounded and occasionally infolded. Variations in signal through the labrum are not indicative of tears. Capsular attachment must be followed from maximum internal to external rotation to identify stripping. The middle and inferior glenoid humeral ligaments often blend with labrum and internal rotation; however, in external rotation they can be identified as distinct and separate structures. Subcoracoid impingement can be identified in maximum internal rotation with a narrowing of the subcoracoid space to < 11 mm and buckling of the subscapularis and lesser tuberosity against the coracoid process. CONCLUSION: Accurate evaluation of the capsular/labral complex requires cine studies for accurate diagnosis. Signal changes alone or labral morphology alone varies through rotation, and static MRI does not accurately assess these morphologic changes, which vary with extremity position. Capsular attachments can be identified with cine studies accurately and reproducibly. Subcoracoid impingement can be identified with a narrowing of the coracohumeral distance to < 11 mm in internal rotation, which is suggestive of pathology.

Arthroscopic assessment of glenoid component loosening after total shoulder arthroplasty.

Component loosening after total shoulder arthroplasty is uncommon. Evaluation of the painful total shoulder can be difficult. Radiography may not be accurate enough to assess component loosening. A retrospective study of nine patients undergoing arthroscopy and later open surgery to confirm arthroscopic findings was undertaken. Plain radiographs correlated with component loosening in two of six patients. Arthrography correlated in one of three patients. Arthroscopy accurately evaluated glenoid component loosening in all patients with this problem. After shoulder arthroplasty patients who develop increasing pain and loss of motion require further evaluation. Radiographic studies appear to be less sensitive than arthroscopic techniques in the evaluation of glenoid component loosening. Arthroscopy has proved to be a valuable technique for the evaluation of patients with painful total shoulder arthroplasty.

MRI diagnosis of tuberculous vertebral osteomyelitis.

Two patients with suspected tuberculous spondylitis and one patient with previous Pott's disease were evaluated preoperatively with magnetic resonance imaging (MRI). The MRI provided more exact anatomic localization of vertebral and paravertebral tuberculous abscesses in multiple planes not previously available with more conventional diagnostic methods in the patients with suspected tuberculous spondylitis. This was helpful for localization in planning of surgical approaches. In the patient with previous Pott's disease, spinal cord compression was detected using MRI, which showed no evidence of active tuberculosis. Two case reports are offered to show the benefit of using MRI as a diagnostic technique in preoperative evaluation and as a method of monitoring treatment response of tuberculous spondylitis. The third case shows the benefit of using MRI to rule out active infection and to detect other forms of spinal pathology.

Rotator cuff disorders.

Rotator cuff problems present with shoulder pain on repetitive overhead activity. Chronic irritation may develop into impingement tendonitis, with weakness of abduction and external rotation and night pain. Conservative management with rest, anti-inflammatory medicine and physiotherapy resolves the majority of symptoms. If these persist, surgical decompression affords good relief of pain.

Isobutyl cyanoacrylate as a soft tissue adhesive. An in vitro study in the rabbit Achilles tendon.

Cyanoacrylates (CAs) are biodegradable, bacteriostatic, and hemostatic adhesives. CAs have been used in medical applications, but with adverse effects, including excessive inflammatory reaction and neural toxicity. Isobutyl CA (ICA) appears more biocompatible, with a long half-life that may be ideal for a soft tissue adhesive. The rabbit Achilles tendon was chosen to test (ICA), and a special muscle-freezing clamp to test this model was designed. The tendons were sharply cut 2 cm proximal to their insertion and repaired in four groups. They were tested to failure on an Instron machine. The breaking strength of the repairs was then noted. Also, the breaking strength of several suture materials was tested. Four Achilles tendon repair groups were evaluated: ICA alone 9.03 newtons (NTS); 4-0 silk Kessler stitch, mean 12.9 NTS; Kessler stitch plus three simple stitches, mean 23.0 NTS; and a combination of (a) and (c)--i.e., suture and adhesive, mean 40.2 NTS. The intact Achilles tendon was tested with an average breaking strength of 317 NTS. The muscle-freezing clamp facilitated reasonable testing of this tendon repair. ICA alone exhibits reasonable strength in vitro and in combination with suture provides a stronger initial repair than either suture or adhesive alone.