Non-operative treatment of subacromial impingement syndrome.

We performed a retrospective study of 616 patients (636 shoulders) who had subacromial impingement syndrome to assess the results of non-operative treatment. The diagnosis was made on the basis of a positive impingement sign and the absence of other abnormalities of the shoulder, such as full-thickness tears of the rotator cuff, osteoarthrosis of the acromioclavicular joint, instability of the glenohumeral joint, or adhesive capsulitis. All patients were managed with anti-inflammatory medication and a specific, supervised physical-therapy regimen consisting of isotonic exercises for strengthening of the rotator cuff. The average duration of follow-up was twenty-seven months (range, six to eighty-one months). Over-all, 413 patients (67 per cent) had a satisfactory result. One hundred and seventy-two patients (28 per cent) had no improvement and went on to have an arthroscopic subacromial decompression. Thirty-one patients (5 per cent) had an unsatisfactory result but declined additional treatment. Seventy-four (18 per cent) of the 413 patients who had a successful result had a recurrence of the symptoms during the follow-up period; the symptoms resolved with rest or after resumption of the exercise program. The patients were stratified according to age, the duration of symptoms, and acromial morphology. Patients who were twenty years old or less and those who were forty-one to sixty years old fared better than those who were twenty-one to forty years old. Patients who were more than sixty years old had the poorest results. Sixty-seven (78 per cent) of the eighty-six patients in whom the symptoms had been present for less than four weeks had a satisfactory result, compared with 144 (63 per cent) of the 228 who had had the symptoms for one to six months and with 202 (67 per cent) of the 302 who had had the symptoms for more than six months. Thirty-two (91 per cent) of the thirty-five patients who had a type-I acromion had a successful result, compared with 173 (68 per cent) of the 256 who had a type-II acromion and with 208 (64 per cent) of the 325 who had a type-III acromion. Shoulder dominance, gender, and concomitant tenderness of the acromioclavicular joint did not affect the result significantly (p = 0.084, 0.555, and 0.365, respectively).

A 45-year-old woman with right shoulder pain.

The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to the orthopedic surgeon. Initial history, physical findings, and roentgenographic examinations are found on the first page. The final clinical and roentgenographic differential diagnoses are presented on the following pages.

Tibial interference screw removal following anterior cruciate ligament reconstruction.

A small number of patients developed pain and tenderness at the tibial tunnel following anterior cruciate ligament reconstruction. Twenty-three knees in 22 patients underwent removal of the tibial interference screw. Ten knees had a preoperative flexion contracture and underwent a concomitant procedure to address the loss of motion at the time of hardware removal. In the 13 knees with full extension, the interval between ligament reconstruction and screw removal averaged 16 months. Eleven of these knees also underwent arthroscopy, but no intra-articular causes of pain were identified. Roentgenographic analysis showed protrusion of the interference screw above the tibial cortex in three cases. Follow-up after hardware removal averaged 2 years. Tibial tunnel tenderness resolved in 21 of 23 knees, including those of the two patients who underwent hardware removal alone. Although it cannot be stated with certainty that tibial interferences screws may cause pain, this review suggests an association. This is an uncommon problem and it is estimated to be a factor in less than 3% of the author's anterior cruciate ligament reconstructions. More common causes of knee pain should be sought before electing to remove the tibial interference screw.

Biomechanical comparison between high tibial osteotomy (HTO) and combined HTO and fibular osteotomy.

The ojectives of this study were to determine the changes in the lateral ligamentous stability of knee joint that occur after performing high tibial osteotomy with and without fibular osteotomy. Utilizing cadaveric specimens, lateral ligamentous stability was assessed by calculating the length of the lateral collateral ligament, and the lateral opening at different flexion angles when varus stress was applied to the tibia. The Polhemus 3-SPACE system was used to collect motion data describing the six-degrees-of-freedom three-dimensional tibiofemoral motions. It was found that the separation distance between the two attachment points of the lateral collateral ligament decreased by an average of 5 mm at all flexion angles after performing a 5-degree valgus high tibial osteotomy. Performing an additional 5-degrees of osteotomy caused this distance to further decrease. It was further found that performing a fibular osteotomy following a 5-degree valgus high tibial osteotomy produced no changes in the length of the lateral collateral ligament. It was also found that the lateral opening increased an average of 5 mm at all flexion angles after performing a 5-degree valgus high tibial osteotomy. Performing a 10-degree osteotomy caused a further increase in the lateral opening. It was further found that performing a fibular osteotomy following a 5-degree valgus high tibial osteotomy caused the lateral opening to return to its original value. That is to say, the fibular osteotomy negated the lateral opening caused by the tibial osteotomy and produced a pattern of lateral opening similar to the one found in the intact knee.

Comparison of perioperative morbidity of anterior cruciate ligament autografts versus allografts.

We present a retrospective report of 50 patients (31 autograft and 19 allograft patients) who underwent arthroscopic bone-patellar tendon-bone anterior cruciate ligament (ACL) reconstructions between August 1988 and September 1990. All patients were followed for a minimum of 2 years. The purpose of this study was to analyze each group regarding hospital stay, swelling, thigh atrophy, laxity, strength, endurance, range of motion, patellofemoral symptoms, and complications. We found no statistical difference between autograft or allograft ACL reconstructions with regard to perioperative morbidity.

Comparison of soft dressing and rigid dressing in the healing of amputated limbs of rabbits.

Thirty white male New Zealand rabbits underwent forelimb amputation below the elbow under sterile operating conditions. Fifteen of the amputation stumps were dressed in a soft, bulky dressing while the remaining 15 rabbits had their stumps immobilized in a rigid plaster dressing. On each of the postoperative days 3, 6, 9, 12 and 15, three rabbits from each group were killed and the amputated limb disarticulated and fixed in formalin. Then, histological examination of the suture line and subcutaneous tissue was carried out by a pathologist to determine the effects, if any, that the type of immobilization has on wound healing. Based on microscopic evaluation of wound approximation, interstitial edema and presence of granulation tissue, there was no significant difference between the stumps immobilized in a plaster dressing and those dressed with a soft, bulky dressing.

Anatomical variations in the first extensor compartment of the wrist. A clinical and anatomical study.

We studied 300 wrists from cadavera and the wrists of forty patients with de Quervain disease to determine the variation in the pattern of the tendons and septa in the first extensor compartment. In 75 per cent of the wrists from cadavera, we found that the number of tendons within the compartment differed from what is considered standard; there was complete or partial septation in 40 per cent. In about a third of the specimens from cadavera, the first extensor compartment was divided by a septum and two tendons or more were present within the major subcompartment. These features might readily result in inadequate decompression of the compartment in the treatment of de Quervain disease. In our prospective study of forty patients with de Quervain disease, septation was found in twenty-seven. There was no significant difference between the number of patients and the number of specimens from cadavera that had no, one, or two accessory abductor tendons.

Coexistent Mycobacterium intracellulare gonarthritis and patellar osteomyelitis in a patient with pulmonary sarcoidosis. A case report and literature review.

We present a 48-year-old man with known pulmonary sarcoidosis who developed septic arthritis of the left knee with concomitant patellar osteomyelitis due to Mycobacterium intracellulare. The patient underwent synovectomy and was started on appropriate combination chemotherapy, but clinical improvement did not occur until patellectomy was performed. Both bone and radiogallium scans were important in the medical and surgical management of this patient.