Posterior capsulorrhaphy for the treatment of traumatic recurrent posterior subluxations of the shoulder in athletes.

Fourteen athletes who failed conservative management for traumatic unidirectional posterior instability of the shoulder and were treated surgically with a posterior capsulorrhaphy procedure were reviewed. Mean duration of follow-up was 45 months (range, 26-90 months). Postoperatively, 13 of the 14 patients achieved good or excellent results according to a modified Rowe grading system and returned to unrestricted sports without recurrence of pain or instability. On the basis of the results of this review, we feel that posterior capsulorrhaphy can provide good results in this specific population of patients--athletes--with the specific diagnosis of traumatic, unidirectional posterior subluxation.

Parsonage-Turner syndrome (acute brachial neuritis).

The cases of seven patients who had had acute brachial neuritis (Parsonage-Turner syndrome) were reviewed retrospectively. The patients had been followed for a mean of six years (range, three to ten years) after the onset of the symptoms. All patients had had an acute onset of intense pain in the shoulder without antecedent trauma. The pain decreased spontaneously and eventually resolved completely in all patients. Weakness in the shoulder had developed at a mean of approximately four weeks after the initial onset of pain. The weakness decreased spontaneously but very gradually in all patients; three patients had persistent, mild weakness at the most recent follow-up evaluation.

Rotator cuff insufficiency in the arthritic shoulder: treatment alternatives.

Shoulder arthroplasty can relieve the pain and improve the functional status of an arthritic shoulder. Because of the unique anatomic characteristics of the glenohumeral joint, the rotator cuff provides stability and control of shoulder motion. Thus, an intact, functioning rotator cuff is necessary for successful shoulder arthroplasty. There are clinical situations where the rotator cuff is torn, absent, or incompetent and an arthritic condition affects the shoulder. The patient must understand that, when confronted with rotator cuff insufficiency and shoulder arthritis, the goal of surgical treatment is limited to pain relief, with shoulder function often limited by the condition of the rotator cuff. We will discuss the incidence of rotator cuff disease associated with differing arthritic conditions, the treatment options available, and expected outcomes in these difficult and challenging clinical situations.

Repair of the rotator cuff. A comparison of results in two populations of patients.

One hundred and seven shoulders of 103 consecutive patients were evaluated after primary repair of the rotator cuff. Twenty-four patients were receiving Workers' Compensation, and the other seventy-nine were not. Preoperative and postoperative evaluation of both groups included subjective assessment of pain, function, and patient satisfaction as well as objective assessment of the strength and active range of motion of the shoulder. The shoulder-rating scale of the University of California at Los Angeles was used to determine over-all success rates. The duration of follow-up ranged from twenty-four to sixty-eight months (mean, forty-five months). The two groups were comparable with regard to the age and sex of the patients, the size of the tear of the rotator cuff, and the preoperative strength, pain, and active range of motion of the shoulder. Over-all, a successful result was achieved in eighty-nine of the 107 shoulders. Of the twenty-four shoulders of patients who were receiving Workers' Compensation, thirteen (54 per cent) were rated good or excellent, compared with seventy-six (92 per cent) of the eighty-three shoulders of patients who were not receiving Workers' Compensation. Ten (42 per cent) of the twenty-four patients who were receiving Workers' Compensation returned to full activity, compared with seventy-four (94 per cent) of the seventy-nine patients who were not.

Rehabilitation of myositis ossificans in the brachialis muscle.

Theories on the etiology and management of myositis ossificans vary greatly. In this article, possible causative factors and treatment options are reviewed. We present a successful treatment regimen for myositis ossificans of the brachialis muscle in a 15-year-old football player. The treatment program emphasizes using joint mobilization and eccentric strengthening early in rehabilitation. The patient regained full elbow range of motion after nine weeks of this rehabilitation program. Follow-up at nine months revealed nearly complete maturation of the heterotopic bone formation, full pain-free range of motion, normal strength, and a safe return to athletic competition.

Evaluation of degenerative lesions of the rotator cuff. A comparison of arthrography and ultrasonography.

A prospective study was performed to determine the accuracy of arthrography compared with ultrasonography in the evaluation of thirty-two patients who had a degenerative lesion of the rotator cuff. Both tests were done preoperatively, and the condition of the rotator cuff was determined intraoperatively. Arthrography was accurate in the diagnosis of twenty-eight (87 per cent) of the thirty-two patients (twenty who had a full-thickness tear, seven who had a partial-thickness tear, and five who had an untorn rotator cuff and tendinitis), while ultrasonography was diagnostic in only twelve (37 per cent). In this specific population of patients, arthrography was found to be superior to ultrasonography.

The impact of the prospective payment system on the treatment of hip fractures in the elderly.

A review of 386 Medicare patients with hip fractures admitted to a private, suburban, teaching hospital from 1981 through 1987 revealed that since the implementation of the prospective payment system in 1984, average hospital stays declined from 17.0 days to 12.9 days (24.1%). Although the mean number of physical therapy sessions declined from 11.1 to 9.8 (11.7%), the average number of treatments per day during the physical therapy phase actually increased from 1.2 before to 1.4 after the prospective payment system. The proportion of patients discharged to nursing homes remained the same (52.9% vs 53.6%); the proportion of patients remaining in a nursing home 6 months after hospital discharge did not differ significantly (22.6% vs 19.9%). Furthermore, there were no differences in the 6-month ambulation status. Total adjusted average hospital charges for the pre- and post-prospective payment system groups did not increase significantly ($7295 vs $7565). These findings do not support the contention that the quality of care provided Medicare patients with hip fractures has deteriorated in this hospital environment.

Fracture of the femoral neck after internal fixation.

A case of femoral neck fracture despite the presence of a previously inserted sliding screw and sideplate is reported. Internal fixation in itself did not prevent subsequent fracture. A critical factor in the mechanism of this fracture was the patient's underlying disease, felt to be alcoholic osteomalacia.

Compartment syndrome resulting from intravenous regional anesthesia.

Three cases of iatrogenic compartment syndrome of the upper extremity are reported. Each was the result of the use of hypertonic saline solution in the administration of intravenous regional anesthesia. Two patients were left with residual problems after resolution of the compartment syndrome despite early surgical intervention in one of these cases. This mechanism may explain other previously reported occurrences of severe swelling in an extremity after intravenous regional anesthesia.

Followup of the acute nonoperated isolated anterior cruciate ligament tear.

This report is an attempt to analyze what happens to an isolated ACL tear that is treated nonoperatively. The results of 40 patients treated initially by nonoperative means for this injury and followed an average of 4 years are reported. A very small percentage of these patients had associated meniscal pathology. Secondary reconstructive surgery was necessary in 12 patients (30%). Primary meniscal tears were present in 4 of 25 knees (16%) and secondary meniscal tears occurred in an additional four of the patients. Giving way was a problem for 36 (86%) of the nonoperated patients, but pain and swelling were not significant problems for most. Full return to unlimited athletic activities was possible for only four (14%) of the patients. Objective signs of ACL insufficiency could be demonstrated on all patients upon clinical examination at followup. Overall grading of the knees revealed 87.5% fair or poor results.

Surgery for full-thickness rotator-cuff tears.

We reviewed the cases of 100 patients who were operated on for a tear of the rotator cuff and found significant improvements in pain in all of them and in function in the majority of patients. The size of the cuff tear did not significantly affect the results, although patients with a smaller tear tended to fare slightly better.

The Indiana conservative (surface-replacement) hip arthroplasty.

We reviewed the clinical results of the Indiana conservative hip arthroplasty in 116 hips with a two to seven-year follow-up. There were seventeen failures (14.6 per cent). The rate of non-traumatic loosening was 10 per cent and the failure rate for patients with inflammatory arthritis was 33 per cent. No infections, dislocations, subluxations, pulmonary emboli, or deaths were associated with the procedure. For forty-two hips with a successful result and a minimum follow-up of three years, the radiographs were analyzed. Factors that were found to have a high correlation with success of the arthroplasty were preservation of the acetabular subchondral bone, complete coverage of the acetabular component, and selection of the appropriate sizes of femoral and acetabular components. Radiolucency was not found to be a reliable diagnostic sign of, or prelude to, symptomatic loosening of the prosthetic implant.

Analysis of revision surgery of resurfacing hip arthroplasty.

Results of revision of 24 resurfacing hip prostheses followed up for a minimum of one year are encouraging. The average Iowa Hip Rating after salvage was higher than the average highest rating prior to failure of the original resurfacing procedure. There were no intraoperative complications in revising any of the failed resurfacing procedures. Results of revision of the failed component of a resurfacing procedure are comparable with those of conversion to a conventional hip arthroplasty. Thorough, prompt evaluation of hip pain in recipients of a hip resurfacing procedure is necessary for preservation of remaining bone stock. In comparison to revision of conventional hip arthroplasty, revision of failed resurfacing hip arthroplasty is technically easier and has a better prognosis in providing the patient with a pain-free, functional hip.

Conservative total hip arthroplasty.

Surface replacement arthroplasty of the hip is a relatively new procedure by orthopedic standards. The test of time is not yet far enough along to allow sound conclusions to be made, but the early results have been encouraging. Most of our failures occurred early in our experience, and our resulting have been steadily improving as our knowledge grows. Significant improvements have been made in surgical technique and prosthetic design. Refinements continue, and we are confident that surface replacement will withstand the test of time and prove to be a useful procedure, especially in younger patients suffering from severe cox arthrosis.