Arthroscopic management of recalcitrant stiffness following rotator cuff repair: A retrospective analysis.

BACKGROUND: Rotator cuff repair surgery is one of the most commonly performed procedures in the world but limited literature exists for guidance of optimal management of post-operative arthrofibrosis following cuff repair. The purpose of this study is to report the results of arthroscopic capsular release, lysis of adhesions, manipulation under anesthesia, and aggressive physical therapy in patients with recalcitrant postoperative stiffness after rotator cuff repair. MATERIALS AND METHODS: Twenty-nine patients who had recalcitrant arthrofibrosis following either an arthroscopic (62%), open (28%), or mini-open (10%) rotator cuff repair were included in study. The average age at the time of index cuff repair surgery was 49.8 years (range 24-70 years). Sixteen patients (55%) were involved in worker's compensation claims. The mean time from the date of index operation to lysis of adhesions was 9.7 months (range 4.2-36.2 months), and the mean time from lysis of adhesion to most recent follow-up 18.2 months (range 4.1-43.7 months). Post-operative evaluation was performed using American Shoulder and Elbow Surgeons Score (ASES), Visual Analog Score (VAS), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) on 18 (62%), while range of motion (ROM), dynamometer strength testing, and Constant-Murley Scoring were performed on 13 (45%). Statistical analysis was performed using a Student's t-test. RESULTS: Prior to arthroscopic lysis of adhesions, mean forward active elevation (FE) was 103.8°, (range 60-145° (SD 26.3) and external rotation at the side (ERS) was 25.3°, (range 5-70° SD 15.1°). Post-operatively, at the most recent follow-up, FE was significantly improved to 158.3°, (range 110-180° SD 22.3°), and ERS improved to 58.9°, (range 15-90° SD 18.6°) in both cases. Involvement in a worker's compensation claim resulted in a lower ASES, VAS, and SANE score, but there was no statistically significant difference in motion. CONCLUSION: Arthroscopic capsular release, lysis of adhesions, and manipulation under anesthesia is a safe, reliable method of treating persistent stiffness following rotator cuff repair.

Stress fractures in athletes.

Stress fractures that occur in the young active population typically represent an overuse injury, and may lead to prolonged periods of restriction from play if they are not treated appropriately. Several risk factors have been identified and must be addressed when treating these patients. Low-risk stress fractures can be successfully treated with activity restriction and a stepwise return to sport. Several pharmacologic and nonoperative treatment modalities have been described. However, high-risk stress fractures are more difficult to treat because they may have an increased rate of delay and nonunion, and often require surgical stabilization. When treating an athlete with a stress fracture, the objective is a safe and quick return to sport; therefore, special considerations must be made in this population, particularly when dealing with the in-season athlete.

Oral corticosteroid use for loss of flexion after primary anterior cruciate ligament reconstruction.

PURPOSE: Postoperative loss of motion after anterior cruciate ligament (ACL) reconstruction can lead to suboptimal outcomes. Short-term low-dose oral corticosteroids are an option for nonsurgical management of this condition. The purpose of this study is to retrospectively review a series of patients treated with a single Medrol Dosepak (MDP) (Pfizer, New York, NY) in the early postoperative period for the treatment of loss of flexion, focusing on range of motion, objective instrumented stability measurements, and complications. METHODS: From September 1, 2003, through January 1, 2007, 28 (11%) of 252 patients who underwent primary ACL reconstruction were treated with an MDP at a mean of 6.1 weeks postoperatively (range, 4 to 12 weeks; SD, 1.4 weeks) for early postoperative loss of motion. Of these 28 patients, 4 were not included because of unavailable clinical records. One patient who underwent combined ACL and posterior cruciate ligament reconstruction with medial collateral ligament repair was excluded from the analysis. Range-of-motion and KT-1000 (MEDmetric, San Diego, CA) measurements were independently recorded by a single examiner preoperatively, at 6 weeks postoperatively, and again at final follow-up evaluation at a mean of 10.4 months (range, 4 to 24 months; SD, 4.3 months). RESULTS: The mean flexion deficit compared with the normal, contralateral knee at the time of treatment with an MDP was 31.3 degrees (range, -2 degrees to 55 degrees ; SD, 14.8 degrees ). Patients treated with an MDP showed a significant improvement in flexion deficit (mean, 29.2 degrees; range, 0 degrees to 60 degrees ; SD, 17.1 degrees ) after MDP treatment (P < .001). KT-1000 side-to-side differences at final examination were 2 mm or less in 22 of 23 patients (mean, 1 mm; range, 0 to 4 mm; SD, 1 mm). Of the 23 patients treated with an MDP, 5 (22%) were considered failures because they required surgical intervention for persistent loss of motion, resulting in a reoperation rate for loss of motion after primary ACL reconstruction of 2.0% (5/252). There were no documented complications of MDP treatment. Specifically, no patients treated with an MDP had a postoperative infection develop. CONCLUSIONS: The use of oral corticosteroids, in the form of an MDP, was associated with a successful return of normal range of motion in 78% of patients with early postsurgical loss of flexion and near-normal extension after primary ACL reconstruction without any associated complications or decrease in objective instrumented stability measurements. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Architectonic subdivision of the human orbital and medial prefrontal cortex.

The structure of the human orbital and medial prefrontal cortex (OMPFC) was investigated using five histological and immunohistochemical stains and was correlated with a previous analysis in macaque monkeys [Carmichael and Price (1994) J. Comp. Neurol. 346:366-402]. A cortical area was recognized if it was distinct with at least two stains and was found in similar locations in different brains. All of the areas recognized in the macaque OMPFC have counterparts in humans. Areas 11, 13, and 14 were subdivided into areas 11m, 11l, 13a, 13b, 13m, 13l, 14r, and 14c. Within area 10, the region corresponding to area 10m in monkeys was divided into 10m and 10r, and area 10o (orbital) was renamed area 10p (polar). Areas 47/12r, 47/12m, 47/12l, and 47/12s occupy the lateral orbital cortex, corresponding to monkey areas 12r, 12m, 12l, and 12o. The agranular insula (areas Iam, Iapm, Iai, and Ial) extends onto the caudal orbital surface and into the horizontal ramus of the lateral sulcus. The growth of the frontal pole in humans has pushed area 25 and area 32pl, which corresponds to the prelimbic area 32 in Brodmann's monkey brain map, caudal and ventral to the genu of the corpus callosum. Anterior cingulate areas 24a and 24b also extend ventral to the genu of the corpus callosum. Area 32ac, corresponding to the dorsal anterior cingulate area 32 in Brodmann's human brain map, is anterior and dorsal to the genu. The parallel organization of the OMPFC in monkeys and humans allows experimental data from monkeys to be applied to studies of the human cortex.