The long head of the triceps: a detailed analysis of its capsular origin.

Whether the triceps brachii muscle provides any significant contribution to stability about the shoulder girdle is unknown. This study seeks to document the anatomy of the origin of the long head of the triceps tendon and to resolve discrepancies in the anatomic literature. Fifteen fresh frozen cadaveric shoulder girdle specimens were dissected, the long head of the triceps and the posterior capsule being exposed. The long head origin averaged 29.5 mm (range, 26-34 mm) in width and 5.7 mm (range, 4-7 mm) in thickness. The average cross-sectional area of origin of the tendon was 168 mm2, and the fibrous contribution from the glenohumeral capsule averaged 2.3% (range, 1.4% to 3.1%) of the tendon's area. A capsular contribution was found in each specimen. The documentation of this capsular contribution may warrant further biomechanical and electromyographic study.

Arthroscopic management of tibial plateau fractures: an unselected series.

The present series reports the results of arthroscopically assisted fixation of tibial plateau fractures. No effort was made to include or exclude any specific fracture type from the all-arthroscopic reduction technique. Fourteen of 17 tibial plateau fractures treated arthroscopically, with an average follow-up of 14.6 months (range, 5-30 months), were retrospectively evaluated. The average patient age was 43 years (range, 25-65 months). The average knee range of motion obtained was 5 degrees-126 degrees, with 9 of 14 patients regaining full symmetric motion. The Lysholm scale was administered to this group with 5 (36%) receiving an excellent rating, 6 (43%) receiving a good rating, and 3 (21%) receiving a poor rating. Two patients experienced complications: one had painful hardware requiring removal, and the other had an infection that resolved after appropriate treatment. The present report advances the treatment of tibial plateau fractures by documenting the feasibility of the arthroscopic management of many fracture types.

In vitro comparison of elongation of the anterior cruciate ligament and single- and dual-tunnel anterior cruciate ligament reconstructions.

This study evaluated strain in the normal anterior cruciate ligament (ACL) and compared it to four different double-strand hamstring tendon reconstructive techniques. Seventeen fresh-frozen knees from 11 cadavers were tested. The strain in the anteromedial and posterolateral bands of the native ACL and their equivalents in four autograft techniques were measured using differential variable reluctance transducers. The anteromedial band of the intact ACL shortened from 0 degree -30 degrees of flexion, then lengthened to 120 degrees; the posterolateral band of the intact ACL shortened from 0 degree - 120 degrees of flexion. Following ACL excision, these knees underwent reconstruction with double-strand hamstring tendons with either single tibial and femoral tunnels, single tibial and dual femoral tunnels, dual tibial and single femoral tunnels, or dual tibial and dual femoral tunnels. With the exception of the dual-band, dual-tunnel technique, all of the procedures placed greater strain on the reconstructive tissues than was observed on the native ACL, after approximately 30 degrees of flexion. These results indicate that dual-band hamstring tendon reconstructions placed with single tibial and femoral tunnels do not address the complexity of the entire ACL. Rather, these procedures appear to only duplicate the effect of the anteromedial band, while perhaps overconstraining the joint as a result of its inability to reproduce the function of the posterolateral band. During rehabilitation following ACL reconstruction, therefore, only from 0 degree - 30 degrees of the graft tissues are not significantly strained. Dual tibial and femoral tunnel techniques should be evaluated further to more closely recreate knee kinematics following ACL reconstruction.

Periarticular neural elements in the shoulder joint.

Due to its unconstrained nature, the glenohumeral joint must necessarily have several mechanisms to regulate its position in space. The neural mechanisms associated with this positioning have not been fully evaluated anatomically. In this study, three fresh-frozen human cadaveric adult shoulders were dissected. Specimens were excised from the proximal biceps insertion, the superior, middle, and inferior glenohumeral ligaments, and the capsule superior to the glenohumeral ligaments. In two specimens, a portion of glenoid labrum was analyzed using a modified gold chloride staining method and light microscopy. A portion of mid-biceps tendon was used as a control. In the superior glenohumeral ligament, 45% of sections contained neural elements consisting of Golgi's, Ruffini's, and Pacini's corpuscles as well as free nerve endings. The predominant types were Ruffini's and Golgi's. The middle glenohumeral ligament sections revealed all four receptor types in 42%, with the most common elements being Pacini's and Ruffini's receptors. The inferior glenohumeral ligament specimens contained the four receptor types in 48% of sections, with Ruffini's, Pacini's, and Golgi's types equally distributed. The shoulder capsule specimens revealed Ruffini's and Pacini's receptors in 47.5% of sections. Only free nerve endings were identified in the biceps tendon and glenoid labral tissue. These findings suggest that the pattern of neural elements does not appear to be random in nature and may have some correlation with the specific functions of some of the glenohumeral ligaments.

The outcomes of two knee scoring questionnaires in a normal population.

The Noyes and Lysholm knee scoring questionnaires, commonly used for follow-up assessment after knee surgery, were developed based on knees with preexisting pathologic changes and have not been standardized to normal knees. We administered both questionnaires to normal subjects. Any subject reporting a history of injury or surgery to either knee, or preexisting knee pathologic changes, was excluded. From a total of 492 knees evaluated, 418 knees (253 male, 165 female) qualified for statistical analysis. The average age of the group was 17.6 years (range, 13 to 25). For male subjects, the total Noyes and Lysholm scores averaged 99.10 (range, 68 to 100) and 99.10 (range, 77 to 100), respectively. For female subjects, the average Noyes and Lysholm scores were 97.82 (range, 72 to 100) and 97.16 (range, 75 to 100), respectively. The 95% confidence interval computed for each of these groups did not contain the maximal value of 100. The female athletes reported significantly lower total scores than the male athletes on both questionnaires. For the Lysholm questionnaire, the male athletes scored significantly lower than the maximum in all categories except support and stair climbing, and the female athletes scored significantly lower than the maximum in all categories except limp and thigh atrophy. The range of scores found in this highly selected, "normal" population exemplifies the need for more accurate instruments in the evaluation of knee surgical outcomes.

Patellar tendon and tibial tubercle reconstruction using quadriceps tendon with patellar bone plug autograft.

This report describes a technique for the reconstruction of a patellar tendon-tibial tubercle deficiency. This technique uses an easy-to-harvest, low-morbidity graft (autogenous quadriceps tendon), while allowing aggressive rehabilitation as a result of the strength of the graft.

Myoelectric and mechanical changes elicited by ischemic preconditioning in the feline hindlimb.

Tourniquet use is fraught with potential complications. For example, ischemia produced by the tourniquet may lead to nerve and muscle injuries. One technique shown in cardiovascular and free-flap surgery to improve the viability of muscle subjected to ischemia is preconditioning. This technique involves an initial brief period of ischemia, followed by reperfusion before a prolonged ischemic episode. The purpose of this study was to explore ischemic preconditioning as a method to reduce tourniquet-related morbidity. In six cats, one leg was preconditioned by 10 min of tourniquet-induced ischemia followed by 10 min of reperfusion. The contralateral limb was not preconditioned. Both limbs underwent 1 h of tourniquet inflation followed by a 2-h recovery period. Isometric force and electromyographic (EMG) amplitude were recorded throughout the procedure at 20-min intervals in both medial gastrocnemius muscles. Analysis of variance (ANOVA) with repeated measures shows that, after 60 min of tourniquet application, maximal isometric force was significantly larger in the preconditioned group. Furthermore, the EMG amplitude during recovery was found to be significantly larger in the preconditioned limbs. These results suggest that preconditioning improves skeletal muscle viability in vivo. Further research is needed, however, to assess the long-term effects of this technique, and to delineate appropriate preconditioning protocols that would improve surgical outcome without significantly increasing the complexity of the procedures.

Arthroscopic versus open reconstruction of the shoulder in patients with isolated Bankart lesions.

We compared open and arthroscopic stabilizations of true Bankart lesions in patients with traumatic, unidirectional anterior glenohumeral dislocations. The 27 patients were men (age range, 18 to 56 years) who were involved in recreational sports. One group (15 patients) had elected an arthroscopic Bankart repair; the other group (12 patients) had chosen open stabilization with a standard deltopectoral approach. Patients were followed up 17 to 42 months after surgery by examination, radiographs, and interviews. In the open repair group, 1 of the 12 patients experienced a subluxation in the follow-up period, but no patients had dislocations or reoperations. In the arthroscopic group, 5 of 15 patients had experienced subluxation or dislocation; of these 5 patients, 2 underwent reoperation. The arthroscopic group had significantly worse results in satisfaction, stability, apprehension, and loss of forward flexion in the operated limb. In summary, the arthroscopic procedure did not significantly improve function; instead, it produced an increased failure rate compared with the open procedure. Therefore, we believe that open stabilization remains the procedure of choice for patients with true Bankart lesions.

Tourniquet-induced tibial nerve palsy complicating anterior cruciate ligament reconstruction.

In this case report, an unremarkable anterior cruciate ligament reconstruction is complicated by a tourniquet-induced tibial nerve palsy. The case underscores the necessity of being aware of the potential for complications associated with tourniquets, despite following recommended guidelines of tourniquet time and pressure.

Bilateral femoral head fracture with posterior hip dislocation.

Bilateral posterior hip dislocations with femoral head fractures are rare. We report the case of a 71-year-old woman who was an unrestrained driver involved in a head-on motor vehicle collision. The right hip was stable after reduction, while the left hip was felt to be unstable. Bilateral bipolar endoprostheses were inserted via standard posterior approaches. Fracture fragments composed approximately 35% of the femoral head in both hips. We believe an elderly polytrauma patient with a significant femoral head fracture may benefit from primary arthroplasty as a treatment option, especially in cases of bilateral injury.

MRI findings of acute turf toe. A case report and review of anatomy.

Normal anatomy of the metatarsophalangeal joint of the hallux has been well described. However, the pathologic anatomy of turf toe, a common injury among football and rugby players, has not been documented in detail. Magnetic resonance images (MRI) of a classic case of turf toe were examined and the findings were compared with MRI of a normal specimen and correlated with known features of gross anatomy. MRI findings confirmed that turf toe involves a sprain or tear of the plantar metatarsophalangeal joint capsule.

The use of MRI in the diagnosis of occult hip fractures in the elderly: a preliminary review.

Establishing the diagnosis of a non-displaced hip fracture in an elderly patient can be a prolonged and costly procedure, involving hospital admission, several days of bed rest, and a bone scan 3 to 5 days later. The authors evaluated 10 hips in 10 patients with a questionable diagnosis of non-displaced hip fracture. Magnetic resonance imaging (MRI) soon after admission revealed four patients with acute hip fractures who were subsequently treated. The other six patients, whose scans were negative for either femoral neck or intertrochanteric fractures, were mobilized. The authors show that, through the use of an immediate MRI study of a questionable hip fracture, the prolonged recumbency and inherent costs associated with awaiting a positive bone scan can be avoided.

Arthroscopic management of tibial plateau fractures.

We report our initial experience with the arthroscopic management of tibial plateau fractures. The known benefits of arthroscopy include better evaluation of the entire joint, limited dissection, and thorough irrigation. We have maximized the potential of arthroscopy through the use of additional instrumentation. With this technique, arthroscopy is used as an operative tool, with the addition of instruments previously used only for ligamentous reconstruction. Some tibial plateau fractures can be treated exclusively arthroscopically, obviating the wide surgical exposures that commonly increase morbidity in these cases.

Clinical experience with unreamed locked nails for open tibial fractures.

Open fractures of the tibia remain a formidable injury. External fixation has been the mainstay of treatment for the more severe fractures. This treatment option, however, is not without significant complications. Of particular importance is the rate of infection once the fixator is converted to a reamed intramedullary nail in cases of delayed union or nonunion. A retrospective review of the records of 20 patients who underwent unreamed, interlocked, intramedullary nailing for tibial fracture has shown that unreamed tibial rodding offers an excellent alternative to external fixation for the management of Grades I and II open tibial fractures. Additionally, for Grade III open fractures, this serves as an excellent form of preliminary stabilization, allowing the soft-tissue injury to heal.