Little Leaguer's shoulder. A report of 23 cases.

Twenty-three cases of Little Leaguer's shoulder were reviewed including the history and physical examination findings, as well as bilateral internal and external rotation anteroposterior comparison radiographs of the proximal humerus. The average follow-up was 9.6 months (range, 1.5 to 54), and all patients were observed until they had either returned to baseball or their symptoms had resolved. The average age of the patients in this series was 14 years. The chief complaint in all patients was pain localizing to the proximal humerus during the act of throwing. The average duration of symptoms was 7.7 months. Nineteen patients (83%) were pitchers. Physical examination revealed tenderness to palpation over the proximal humerus in 20 patients (87%), with 16 (70%) demonstrating specific tenderness over the lateral aspect of the proximal humerus. Swelling, weakness, atrophy, and loss of motion were uncommon findings. All 23 patients demonstrated radiographic widening of the proximal humeral physis of the throwing arm on internal and external rotation comparison anteroposterior radiographs of the shoulder. All patients were treated with rest from baseball throwing for an average of 3 months. Twenty-one of the 23 patients (91%) returned to playing baseball and were asymptomatic. The classic radiographic finding of widening of the proximal humeral physis can easily be seen on bilateral anteroposterior internal and external rotation radiographs of the proximal humerus. Rest from throwing for at least 3 months is recommended, followed by a gradual return to throwing in an asymptomatic shoulder.

Toxicity of linear furanocoumarins toSpodoptera exigua: Evidence for antagonistic interactions.

The linear furanocoumarins psoralen, bergapten, and xanthotoxin were tested for toxicity to the beet armywormSpodoptera exigua (Hübner) under short ultraviolet (UVB) radiation. Increased dietary concentrations of each furanocoumarin significantly decreased insect larval weight, extended generation time, and induced higher mortality. Xanthotoxin was the most toxic, followed by psoralen and bergapten. Combining psoralen with bergapten, xanthotoxin, or both resulted in significantly antagonistic effects on insect mortality. The combination of bergapten and xanthotoxin, however, produced additive effects. The implications of these observations forS. exigua resistance in the wild plant accession ofApium prostratum and the enigma the findings represent for plant-insect relationships are discussed.

Arthroscopy of the shoulder: anatomy and technique.

Diagnostic and operative arthroscopy of the shoulder is a reasonably demanding surgical procedure. The surgeon performing this procedure is required to have a detailed knowledge of the arthroscopic anatomy of the shoulder. In addition, adherence to strict surgical technique is necessary to prevent complications. Attention to detail is required for all phases of shoulder arthroscopy, including patient positioning, draping, outlining of bony landmarks, and exact placement of arthroscopic portals.

A new technique of harvesting patellar tendon autografts for anterior cruciate ligament reconstruction.

A new surgical technique to uniformly harvest the middle one-third of the patellar tendon for anterior cruciate ligament reconstruction is described. The technique uses a guide system of 8 templates of varying widths to guide the saw cuts and "collared," depth-controlled saw blades and drill bits to produce a standard cutting and drilling depth. This kind of template system lessens the risks of graft harvesting complications such as patella fracture, bone graft fragmentation, suture pull out, and judgment errors pertaining to graft depth, length, or width. The Patellar Tendon Graft Guide was used to obtain a patellar tendon graft in 65 patients. Fifty-nine arthroscopic-assisted and 6 open anterior cruciate ligament reconstructions were performed. Of the 65 grafts harvested, 63 consistently demonstrated bone portions 20 mm in length, 7 mm in depth, and a width corresponding to the template chosen (usually 10 mm). Two grafts supposed to be 10 mm in width turned out to be 9 mm in width because of a technique related problem.

Impact of UV radiation on activity of linear furanocoumarins andBacillus thuringiensis var.Kurstaki againstSpodoptera exigua: Implications for tritrophic interactions.

Acidic fogs with a pH of 2.0 and duration of 2 hr did not reduce the efficacy ofBacillus thuringiensis var.Kurstaki (Berliner). Therefore, the impact of UV radiation was investigated on the interactions between (1) levels of the antibacterial linear furanocoumarins psoralen, bergapten, and xanthotoxin inApium graveolens (L.) occurring following a 2.0 pH acidic fog episode, (2) the noctuidSpodoptera exigua (Hübner), and (3) a sublethal dosage of the microbial pathogenB. thuringiensis var.Kurstaki. Mean time to pupation in the absence of UV radiation (survival was too low to conduct this analysis for insects exposed to UV) was significantly extended by the addition of either psoralens orB. thuringiensis. Larvae developing on diets containingB. thuringiensis plus psoralens required nearly 40% longer to pupate than controls, but their effects were additive as the interaction was not significant. Although the mean times to adult emergence were significantly different, time spent in the pupal stage did not vary significantly between treatments, indicating that increases in larval developmental time were responsible for the observed decrease in developmental rate. Mean time to mortality, a weighted average time of death, was not significantly affected by any of the treatments. In a 2 × 2 × 2 factorial analysis, all main effects (linear furanocoumarins.B. thuringiensis, UV radiation) reduced survival significantly, as did the three-way interaction. Thus, antagonistic interactions with psoralens that would reduce the effectiveness ofB. thuringiensis in the field were not observed. When pairs of main effects were nested within the two levels (presence and absence) of the third factor, several two-way interactions were found. Interestingly, the activity ofB. thuringiensis and the psoralens, individually or in combination, was enhanced by exposure to UV radiation. Implications of this research are discussed for both natural and agricultural ecosystems.

Arthroscopic techniques to improve access to posterior meniscal lesions.

Unsatisfactory results following partial meniscectomy and problems related to a retained posterior horn of the medial meniscus are problems often attributed to inadequate arthroscopic partial meniscectomy. Although there are multiple techniques to gain better access to the various compartments in a truly tight knee, most of the problems in obtaining maximum visualization and instrumentation to the posterior aspects of the medial or lateral meniscus can usually be solved by adhering to a strict surgical technique that attempts to control the multiple variables encountered during arthroscopic surgery. These include the use of a tourniquet, leg holder, maximum distention of the knee provided by a large inflow cannula with large-bore tubing connected to 3-L bags, and an 18-gauge needle as a predecessor to the larger arthroscopic instruments. Of utmost importance is establishing the correct portal for the arthroscope, and it is time well spent at the beginning of the surgical procedure to verify the proper location of the arthroscope and not simply insert the arthroscope "a thumb-breadth above the joint line." Once these variables have been controlled, one can usually visualize and perform arthroscopic surgery on most meniscal lesions with minimal scuffing to the articular surfaces.

Rehabilitation of the throwing shoulder.

Rehabilitation of the injured throwing arm should not be directed simply toward beginning strengthening exercises and returning the athlete to throwing as soon as possible. The total comprehensive program has been described and consists of seven phases that begin with making the proper diagnosis of a shoulder injury. Once the proper diagnosis is made, the pathophysiology of throwing injuries has to be understood by the physician, the trainer, and the athlete, and then the actual treatment begins in phase III. Initial treatment many times consists of a short period of relative rest as well as physical therapy modalities to relieve pain, and once pain is relieved phase IV begins, which is the actual techniques of range of motion, flexibility, and strengthening maneuvers. Once adequate flexibility, range of motion, and pain-free motion have been achieved, as well as adequate endurance strength, proper warm-up techniques are begun, and then a return to throwing is achieved in phase VI. The total rehabilitative cycle is concluded with phase VII, which consists of an off-season conditioning program to verify that the athlete will maintain year-round maximum condition of not only the throwing shoulder but of the entire athlete.

The role of lateral extra-articular procedures for anterolateral rotatory instability.

The goal of any surgical procedure to correct the instability caused by loss of the ACL is to control the abnormal anterior excursion of the tibia on the femur. Because the main problem is loss of the ACL, it would seem most reasonable to approach this problem by performing an intra-articular reconstruction of the ACL, thus approximating as closely as possible the normal anatomy of the ACL. The classic open intra-articular ACL reconstructions are technically demanding surgical procedures that usually require a significant "learning curve" to achieve a level of technical expertise and confidence. In addition, postoperative complications such as adhesions, loss of motion, prolonged muscle atrophy, and a long rehabilitation period are well known. Thus, it would appear that the extra-articular reconstructive procedures for the anterior cruciate-deficient knee would offer some advantage over these more formidable surgical procedures. Whereas the main problem is certainly the loss of the ACL, the extra-articular procedures are directed more toward the most symptomatic anterior excursion of the tibia on the femur, the pivot shift phenomenon, where the anterolateral portion of the tibia moves anterior in relation to the femur. Thus, the goal of the extra-articular reconstructive procedures for anterolateral rotatory instability is to eliminate functional instability. These goals are most readily achieved by positioning some portion of the iliotibial tract posterior to the transverse center of rotation of the knee to provide a reinforcement for the lateral tibial plateau as the knee approaches terminal extension. All of the extra-articular procedures discussed in this article have been used successfully as reported by the various authors. There are many technical details inherent in each of these surgical procedures, and the reader is referred to the original articles for a more explicit description of these surgical procedures. For the individual surgeon to participate in and view the actual surgical procedure that he or she intends to perform would be the ideal situation. Various workshops where surgical procedures of the knee are actually performed and studied are currently available and are of great value to the surgeon. Of equal importance to the technical demands of the various surgical procedures is selection of the appropriate procedure for each patient. The selection must be based on many factors. The most important factor is the identification of the patient with a high level of athletic activity who is unwilling to modify his or her activity level to compensate for a deficient ACL.(ABSTRACT TRUNCATED AT 400 WORDS)

Arthroscopy of the elbow.

Arthroscopy of the elbow is a technically demanding surgical procedure and attention to detail is essential. The surgeon needs a thorough knowledge of the extraarticular portal anatomy to avoid damaging nearby neurovascular structures. Several technical points need to be considered at all times, especially maintaining the elbow at 90 degrees of flexion to relax the neurovascular structures and maximally distended to move them farther away from the entering arthroscopic instruments.

Arthroscopy of the ankle.

This article describes the surgical technique of arthroscopy of the ankle and the indications for its use. In addition to describing the common anterolateral and anteromedial arthroscopic portals, a discussion is also given regarding portal anatomy of ankle arthroscopy and the various neurovascular structures that lie in close proximity to the arthroscopic portals. Arthroscopy of the ankle has a definite role in the management of certain lesions of the ankle, such as loose bodies, or osteochondral or chondral defects of the talus. Ankle arthroscopy is a technically demanding surgical procedure and great attention to detail is required to perform this procedure in a safe and reproducible fashion.

Arthroscopy of the elbow.

For arthroscopy of the elbow to be safe and effective, the arthroscopist must develop a systematic and reproducible arthroscopic examination technique. We believe that the technique and the identification of anatomic structures described in this article provide a safe and reliable means of performing this procedure. Attention to detail, especially when establishing the portals, is essential in performing a safe examination and in avoiding damage to the neurovascular structures. We prefer the 4-mm, 30-degree-angled arthroscope. It provides the wide field of view necessary for both diagnostic and operative elbow arthroscopy. The large percentage of excellent and good results in patients who have had correction of mechanical disorders of the elbow has been encouraging. Removal of loose bodies and resection of impinging olecranon osteophytes produced the best functional results. Chondroplasties of the radial head and capitellum produced less satisfactory results than did the correction of mechanical disorders. In conclusion, arthroscopy of the elbow is an effective diagnostic procedure and is effective in treating certain intraarticular problems with minimal morbidity and rapid return to function. However, attention to detail is essential to prevent compromise of the surrounding neurovascular structures or damage to the delicate articular cartilage.

Glenoid labrum tears related to the long head of the biceps.

Tears of the glenoid labrum were observed in 73 baseball pitchers and other throwing athletes who underwent arthroscopic examination of the dominant shoulder. Most of the tears were located over the anterosuperior portion of the glenoid labrum near the origin of the tendon of the long head of the biceps muscle into the glenoid. At arthroscopy, the tendon of the long head of the biceps appeared to originate through and be continuous with the superior portion of the glenoid labrum. In many cases it appeared to have pulled the anterosuperior portion of the labrum off the glenoid. This observation was verified at arthroscopy by viewing the origin of the biceps tendon into the glenoid labrum as the muscle was electrically stimulated. With stimulation of the muscle, the tendinous portion became quite taut, particularly near its attachment to the glenoid labrum, and actually lifted the labrum off the glenoid. Three-dimensional high-speed cinematography with computer analysis revealed that the moment acting about the elbow joint to extend the joint through an arc of about 50 degrees was in excess of 600 inch-pounds. The extremely high velocity of elbow extension which is generated must be decelerated through the final 30 degrees of elbow extension. Of the muscles of the arm that provide the large deceleration forces in the follow-through phase of throwing, only the biceps brachii traverses both the elbow joint and the shoulder joint. Additional forces are generated in the biceps tendon in its function as a "shunt" muscle to stabilize the glenohumeral joint during the throwing act.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopy of the ankle: technique and normal anatomy.

The authors present a modified technique of ankle arthroscopy and describe the intra-articular anatomy of the ankle joint as it relates to the establishment of arthroscopic portals. Cadaveric dissection was used to demonstrate the relationship of the tendons and neurovascular structures to the placement of the arthroscope. Diagnostic arthroscopy of the ankle can be systematic and reproducible when the surgeon is knowledgeable of the intra-articular and extra-articular anatomy of the ankle and when attention is given to accurate placement of the arthroscopic portals and to consistent surgical technique.

Extra-articular reconstruction of the anterior cruciate ligament: lateral procedures.

Several extra-articular procedures have been shown to be successful in controlling anterolateral rotatory instability. These procedures are performed as an extra-articular reconstruction alone or are combined with an intra-articular reconstruction. The common goal of these extra-articular procedures is the control of the abnormal anterior subluxation of the lateral tibial plateau and, thus, the elimination of the lateral pivot shift phenomenon. This goal is achieved most readily by placing some portion of the iliotibial tract posterior to the transverse center of rotation of the knee in order to provide a check-rein effect on the lateral tibial plateau to prevent anterior subluxation as the knee approaches terminal extension.

Diagnosis of extensor mechanism disorders.

A comprehensive physical examination of the patellofemoral joint and the entire lower extremity is often required to detect some of the more subtle extensor mechanism disorders. The standing, sitting, and supine examinations of the patient with patellar complaints are presented. In addition, the various radiographic techniques available to evaluate the patellofemoral joint are reviewed.

Arthroscopy of the shoulder in the management of partial tears of the rotator cuff: a preliminary report.

Thirty-six patients with partial tears of the supraspinatus portion of the rotator cuff underwent arthroscopic examination and debridement of the lesion. All patients, whose average age was 22 years, were involved in competitive athletics; 64% were baseball pitchers. The average duration of symptoms prior to arthroscopy was 12 months. The most common presenting complaint was pain felt in the shoulder during overhead activities. Associated pathology included tears of the glenoid labrum and partial tearing or tendinitis of the long head of the biceps tendon. Of the 34 patients available for follow-up, 26 (76%) had excellent results, three (9%) had good results, and five (15%) had poor results. Eighty-five percent of the patients returned satisfactorily to their preoperative athletic activity. Our preliminary experience with arthroscopy of the shoulder in the management of patients with partial rotator cuff tears is encouraging. Not only can a partial rotator cuff tear be debrided to initiate a healing response, but a definitive diagnosis can also be made and associated pathology identified, permitting the establishment of an appropriate rehabilitation program.

Arthroscopy of the elbow.

A technique of diagnostic and surgical arthroscopy of the elbow is presented, and the normal intraarticular anatomy as viewed from the anterolateral, anteromedial, and posterolateral portals is described. A preliminary study of 12 patients who underwent surgical arthroscopy of the elbow demonstrated that removal of loose bodies produced the best objective and subjective results. Less satisfactory results were obtained when procedures such as capitellum and radial head chondroplasties were performed. Using a preoperative and postoperative point accumulation rating system for four objective and four subjective criteria, the following results were noted. Before surgery 50% of the patients objectively rated their elbows as satisfactory (excellent or good), whereas postoperative ratings increased to 83%. Subjectively, 17% rated their elbows as satisfactory before surgery, improving to 58% satisfactory ratings postoperatively. The only complication was a transient median nerve palsy caused by the extracapsular extravasation of a local anesthetic. From this preliminary study, it was concluded that attention to detail is essential in performing a safe, reproducible arthroscopic examination of the elbow, that arthroscopy of the elbow is an effective diagnostic procedure, and that operative elbow arthroscopy is effective in the treatment of certain elbow disorders.

Patellofemoral disorders: physical and radiographic evaluation. Part I: Physical examination.

Patellofemoral disorders present a diagnostic and therapeutic challenge to the orthopedic surgeon. By the sequential application of such basic diagnostic tools as inspection, palpation, and various measurements to a patient in standing, sitting, supine, and prone positions, a reproducible, comprehensive physical examination of the patellofemoral joint and entire lower extremity may be achieved.