The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality.

Labral tears and acromioclavicular joint abnormalities were differentiated on physical examination using a new diagnostic test. The standing patient forward flexed the arm to 90 degrees with the elbow in full extension and then adducted the arm 10 degrees to 15 degrees medial to the sagittal plane of the body and internally rotated it so that the thumb pointed downward. The examiner, standing behind the patient, applied a uniform downward force to the arm. With the arm in the same position, the palm was then fully supinated and the maneuver was repeated. The test was considered positive if pain was elicited during the first maneuver, and was reduced or eliminated with the second. Pain localized to the acromioclavicular joint or "on top" was diagnostic of acromioclavicular joint abnormality, whereas pain or painful clicking described as "inside" the shoulder was considered indicative of labral abnormality. A prospective study was performed on 318 patients to determine the sensitivity, specificity, and positive and negative predictive values of the test. Fifty-three of 56 patients whose preoperative examinations indicated a labral tear had confirmed labral tears that were repaired at surgery. Fifty-five of 62 patients who had pain in the acromioclavicular joint and whose preoperative examinations indicated abnormalities in the joint had positive clinical, operative, or radiographic evidence of acromioclavicular injury. There were no false-negative results in either group.

Osteochondritis dissecans of the femoral condyles. Long-term results of excision of the fragment.

Nineteen patients with 20 osteochondritis dissecans lesions were evaluated between 2 and 20 years after excision of a partially detached (grade III) or loose (grade IV) fragment from the femoral condyles. Evaluation with the Hughston rating scale for osteochondritis dissecans revealed one excellent result, four good, four fair, six poor, and five failure results. Eleven patients had developed osteochondritis dissecans before skeletal maturity. In contrast to what has been stated in the literature, the results in these patients were no better than in those who developed osteochondritis dissecans as adults. The short-term results of excision are good, but the long-term results are extremely poor. Consequently, we recommend bone grafting and replacement of the fragment when it is technically possible because the long-term results are better than those after excision.

Antegrade drilling for osteochondritis dissecans of the knee.

Twenty-four knees with osteochondritis dissecans of the femoral condyles failed a conservative program and were treated with antegrade drilling. To our knowledge, this represents the largest reported series using this technique. The average age at the time of surgery was 13 years 6 months. Seventeen patients had open physes, and four were skeletally mature. Nineteen lesions involved the medial femoral condyle, and five involved the lateral femoral condyle. The average follow-up was 5 years. Postoperative evaluation included rating by the International Knee Documentation Committee (IKDC) form and the Hughston Rating Scale for osteochondritis dissecans. Twenty of the 24 lesions healed after antegrade drilling, and the average time of healing was 4 months. According to the criteria on the IKDC grading form, 14 were normal, 6 nearly normal, three abnormal, and one severely abnormal. The results of the Hughston Rating Scale were similar: 15 were excellent, seven good, one fair, and one poor. Only two of the four skeletally mature patients healed after antegrade drilling. Antegrade drilling is an effective method of treatment for osteochondritis dissecans of the knee that occurs in adolescents with open physes. This operation is not as likely to result in a successful outcome in patients with closed physes; consequently, other methods should be considered in skeletally mature patients.

An arthroscopic technique for anterior stabilization of the shoulder with a bioabsorbable tack.

Arthroscopically assisted repair of the anterior aspect of the labrum with use of a bioabsorbable tack was performed in fifty-two consecutive patients who had chronic anterior instability of the shoulder. The average age of the patients was twenty-eight years (range, sixteen to fifty years). The etiology of the instability was a traumatic injury in forty-nine patients; twenty-six of those injuries were sustained during participation in a contact sport. Fifty shoulders had a Bankart lesion. The patients were evaluated at an average of forty-two months (range, twenty-four to sixty months) after the procedure. Forty-one (79 per cent) of the patients were asymptomatic and were able to participate in sports without restriction. The repair was considered to have failed in eleven (21 per cent) of the patients. In four of them, the failure resulted from a single traumatic reinjury during participation in a contact sport, and three of these reinjuries were treated nonoperatively. The remaining seven failures occurred atraumatically. Eight patients had an open glenoid-based capsulorrhaphy as a consequence of recurrent instability. At the reoperation, no evidence of the tack was found in any patient. In seven patients, the Bankart lesion had completely healed, and the anteroinferior aspect of the capsule was patulous. Anterior stabilization of the shoulder with a bioabsorbable tack may be indicated for patients who have anterior instability but do not need a capsulorrhaphy or capsular imbrication to reduce the joint volume.

Humeral head osteonecrosis: clinical course and radiographic predictors of outcome.

Forty-two patients (65 shoulders) with osteonecrosis of the humeral head were reviewed. Minimal follow-up was 2 years or until shoulder arthroplasty was performed for persistent severe pain and disability not responsive to conservative treatment. Thirteen shoulders had surgery shortly after presentation, whereas 22 others initially treated conservatively required surgery. Thirty shoulders in 20 patients have been treated without surgery and were evaluated at an average of 10 years after initial presentation. Fifteen shoulders are doing satisfactorily, whereas 15 others are doing poorly. Overall, 37 (71%) shoulders had clinical progression of disease requiring shoulder arthroplasty or resulting in severe pain and disability. All had radiographic stage III, IV, or V, and 41 (85%) had articular surface incongruity of 2 mm or greater. Humeral head drilling was not effective in preventing clinical or radiographic progression in stage III.disease. Radiographic stages of III or greater and documented radiographic disease progression were significantly associated with a poor outcome.

A muscle-splitting approach to the ulnar collateral ligament of the elbow. Neuroanatomy and operative technique.

The standard surgical approach for repair or reconstruction of the ulnar collateral ligament of the elbow involves lifting off of the tendon of the common flexor bundle at its origin on the medial epicondyle. However, a more limited muscle-splitting approach may be feasible. A muscle-splitting approach is less traumatic to the flexor-pronator muscle mass, and it could decrease operative time and lessen immediate morbidity after surgery. A proposed muscle-split through the common flexor bundle extends from the medial humeral epicondyle to a point distal to the tubercle of the ulna such that repair or reconstruction can be performed on the ulnar collateral ligament. To examine the feasibility of this approach, we performed a study combining anatomic dissections with clinical observations. We dissected 15 fresh-frozen adult cadaveric elbows to examine the neuroanatomy of the medial side of the elbow. All pertinent nerves were identified and mapped. From these data, we defined a "safe zone" for a muscle-splitting approach to the ulnar collateral ligament that allows adequate room for repair or reconstruction of the ligament without risking denervation of the surrounding musculature. The safe zone extends from the medial humeral epicondyle to approximately 1 cm distal to the insertion of the ulnar collateral ligament on the tubercle of the ulna. Twenty-two patients with ulnar collateral ligament tears underwent either a direct repair or a reconstruction of the ligament using the proposed muscle-splitting approach. With a minimum followup of 1 year, there was no clinical evidence of muscle denervation. From the combined anatomic study and clinical data, we believe that a less traumatic muscle-splitting approach to the ulnar collateral ligament affords a safe and simple surgical approach for repair or reconstruction of the ligament.

Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum followup.

Thirty-seven of 41 consecutive patients with recurrent anterior instability of the shoulder were retrospectively observed for a mean of 5.6 years (range, 4 to 10) after an arthroscopic stabilization procedure had been performed. The operative technique involved the use of transglenoid sutures to repair the capsule and labrum. According to the criteria established by Rowe, 27 patients (74%) had good or excellent results, and 3 patients (7%) were graded as fair. Seven patients (19%) developed recurrent instability after the procedure and had failed results. Failure rates were equal in patients with a history of recurrent dislocation and those with recurrent subluxation. Absence of a Bankart lesion at operation was associated with postoperative instability (P = 0.03). The presence or size of humeral head defects did not influence the result. Eight of 12 athletes who engaged in sports requiring repetitive overhead shoulder motion returned to full activity, and none of the 12 developed instability after operation. Four of the 13 patients who participated in contact sports or recreational skiing developed postoperative instability (P = 0.21). All failures occurred within 2 years of the procedure.

Role of the long head of the biceps brachii in glenohumeral stability: a biomechanical study in cadavera.

Ten cadaveric shoulders were tested to evaluate the effect of simulated contraction of the long head of the biceps brachii on glenohumeral translation. The shoulders were mounted on a special apparatus attached to a servo-controlled hydraulic testing device. Sequential 50 N anterior, posterior, superior, and inferior forces and a 22 N joint compressive load were applied to the shoulders. An air cylinder applied a constant force to the tendon of the long head of the biceps brachii. The shoulders were tested in seven positions of glenohumeral elevation and rotation. Application of a force to the long head of the biceps brachii resulted in statistically significant decreases in humeral head translation. The influence of the long head of the biceps was more pronounced at middle and lower elevation angles. When the shoulder was placed in 45 degrees of elevation and neutral rotation, application of a 55 N force to the biceps tendon reduced anterior translation by 10.4 mm (p = 0.001), inferior translation by 5.3 mm (p = 0.01), and superior translation by 1.2 mm (p = 0.004).

Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation.

Lesions of the superior portion of the glenoid labrum were created in seven cadaveric shoulders. The shoulders were mounted on a special apparatus attached to a servocontrolled hydraulic materials-testing device. Sequential fifty-newton anterior, posterior, superior, and inferior forces and a twenty-two-newton joint compressive load were applied to the shoulders. In addition, a fifty-five-newton force was applied to the tendon of the long head of the biceps brachii. The shoulders were tested in seven positions of glenohumeral elevation and rotation. An isolated lesion of the anterosuperior portion of the labrum, which did not involve the supraglenoid insertion of the biceps brachii, had no significant effect on anteroposterior or superoinferior glenohumeral translation, either with or without application of the fifty-five-newton force to the biceps brachii tendon. In contrast, a complete lesion of the superior portion of the labrum that destabilized the insertion of the biceps resulted in significant increases in anteroposterior and superoinferior glenohumeral translations. At 45 degrees of glenohumeral elevation, the complete lesion led to a 6.0-millimeter increase in anterior translation when the arm was in neutral rotation and to a 6.3-millimeter increase when the arm was in internal rotation; inferior translation also increased, by 1.9 to 2.5 millimeters. The increases in translation persisted despite application of a fifty-five-newton force to the long head of the biceps.

Symptomatic ossification of the tibiofibular syndesmosis in professional football players: a sequela of the syndesmotic ankle sprain.

Ankle syndesmosis sprains are common injuries in collegiate and professional football. Several reports have documented that patients with syndesmosis injuries require a longer time to return to full athletic participation than patients with lateral ankle sprains. Here we present the cases of two professional football players with ankle pain secondary to syndesmosis ossification following documented syndesmosis ankle sprains. Both patients eventually required resection of the heterotopic ossification to allow a pain-free return to football. We conclude that syndesmosis ossification may be symptomatic in some patients, and surgical excision of the ossification may be required to allow an asymptomatic return to sports.

Arthroscopic fixation of superior labral lesions using a biodegradable implant: a preliminary report.

Twenty-two patients were treated for symptomatic lesions of the superior glenoid labrum in association with instability of the tendinous insertion of the long head of the biceps brachii. A biodegradable implant was used to fix the labrum to the bony glenoid using an arthroscopic technique. At 2-year average follow-up, satisfactory results were obtained in 86% of the patients. Two patients, both of whom had undergone concomitant subacromial decompression, continued to complain of pain after the procedure; 3 patients had restricted motion postoperatively, and 1 required manipulation under anesthesia. Twelve of 13 overhead athletes were able to return to full premorbid function. Arthroscopic fixation of unstable lesions of the superior labrum led to a resolution of symptoms in the majority of patients. There were no complications related to the use of the biodegradable implant.

Postoperative femoral fracture after intramedullary fixation with a Gamma nail: case report and review of the literature.

The Gamma nail, an intramedullary nail that is combined with a sliding hip screw, has recently been introduced as an alternative method of treatment for peritrochanteric fractures of the femur. We report a case of a postoperative femoral fracture that occurred in the area of the device after Gamma nailing of a stable intertrochanteric fracture. A review of the literature reveals that postoperative fracture is not an uncommon complication of Gamma nailing. This complication results in a difficult management problem. The possibility of a femoral fracture around the Gamma nail should be entertained before the use of the nail is considered. The availability of alternative fixation devices must be confirmed in the event that such a fracture is encountered.

Internal fixation of proximal humerus fractures using the screw-tension band technique.

Many of the current techniques of internal fixation of proximal humerus fractures use tension band wires to achieve secure fixation, allowing immediate postoperative exercise of the affected limb. In addition, the use of a cancellous lag screw placed from the humeral shaft into the humeral head may have several advantages. In particular, this lag screw does not violate the subacromial space and provides initial stability between the head and shaft, which facilitates placement of the tension band wires. This technique was used in 13 patients whose average age was 71 years (range 54-86). Follow-up averaged 20 months. Eight patients had two-part fractures and five patients had three-part fractures. This technique used a deltopectoral approach with manual impaction of the humeral head and shaft. A 6.5-mm AO screw was used for lag screw fixation in addition to two 18-gauge tension band wires: one placed through the tuberosities and one under the rotator cuff tendons. Passive range of motion of the involved shoulder was begun with the first postoperative week, and active range of motion and strengthening were allowed after the fourth postoperative week. At follow-up patients were evaluated for range of motion, function, pain, and radiographic appearance of the fracture. Average forward flexion was 160 degrees, external rotation was 46 degrees, and internal rotation was to the 10th thoracic vertebra. According to the functional scale proposed by Hawkins, 10 of the 13 patients had achieved a good result. Two of the remaining patients had a fair score, and one had a poor outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Anatomic considerations in harvesting the semitendinosus and gracilis tendons and a technique of harvest.

Although the semitendinosus and gracilis tendons have long been used in ligamentous reconstruction procedures of the knee, their anatomic relationships have not been explicitly detailed. Therefore, cadaveric dissections were performed on fresh-frozen adult knees to examine these relationships. Several key anatomic points are useful in the harvest of these tendons. Their conjoined insertion site is medial and distal to the tibial tubercle. They become distinct structures at a point that is farther medial and slightly proximal. Tendon harvest is facilitated by identifying the tendons proximal to this point. The superficial medial collateral ligament lies deep to the tendons in this area and should not be disturbed. The tendons are ensheathed in a dense fascial layer that may impede tendon stripping. The accessory insertion of the semitendinosus tendon (which was present in 77% of the knees dissected) should be identified and transected to avoid tendon damage at harvest. Knee flexion may reduce the risk of injury to the saphenous nerve as it crosses the gracilis tendon. Variation in tendon diameter affects graft strength.

Multidirectional instability: medial T-plasty and selective capsular repairs.

Multidirectional instability of the shoulder present a unique challenge in management. The patient with multidirectional instability classically is seen without a history of significant trauma to the shoulder; however, posttraumatic multidirectional instability may be encountered in the athletic population. Patients with an atraumatic etiology often respond to nonoperative rehabilitative measures, whereas those with a traumatic etiology are more likely to require surgical intervention. Standard operative stabilization procedures for unidirectional instability are likely to fail in the patient with multidirectional instability.

Effect of aspirin on heterotopic ossification after total hip arthroplasty in men who have osteoarthrosis.

The severity of heterotopic ossification was determined from the radiographs of eighty-three men in whom osteoarthrosis had been treated with a primary total hip arthroplasty with cement. The medical records of these patients were then reviewed, with the reviewer having no knowledge of the radiographic findings. A similar operative approach and technique had been used in all patients. There was no association between the amount of intraoperative loss of blood or the duration of the operation and the severity of formation of heterotopic bone. The over-all rate of occurrence of heterotopic ossification was 72 per cent. Of the fifty-eight patients who had received aspirin throughout their course in the hospital, two (3 per cent) had severe ectopic ossification (grade III or IV8). In contrast, twelve (48 per cent) of the twenty-five patients who had received no aspirin or in whom aspirin had been discontinued so that anticoagulation could be begun had severe heterotopic ossification. The difference in the severity of the ossification between the two groups is significant (p less than 0.0001).

Extrusion of the medial meniscus.

Disruption of the anchoring points of the menisci of the knee has been hypothesized to result in subluxation of the affected meniscus from the articular surface. A case report of such an extrusion of the medial meniscus is presented. Medial subluxation of the meniscus from the tibiofemoral articulation occurred as a result of avulsion of the posterior horn with concomitant medial collateral and posterior cruciate ligament injuries.

Cooperation in oncogenesis between BK virus early region gene and the activated human c-Harvey ras oncogene.

Rapidly growing, undifferentiated brain tumours were induced in newborn Syrian hamsters by intracerebral inoculation of a recombinant DNA (pBK/c-rasA) carrying the BK virus (BKV) early region gene and the activated human c-Harvey-ras (c-Ha-ras) oncogene. Neither of the two genes inoculated alone nor recombinant DNA of the BKV early region gene and the normal human c-Ha-ras proto-oncogene were tumourigenic. Tumour-derived cell lines propagated in culture were immortalized and had growth characteristics consistent with a fully transformed phenotype. Tumours and tumour cell lines contained pBK/c-rasA sequences integrated into cellular DNA and expressed BKV- and c-Ha-ras-specific transcripts as well as BKV T antigen and c-Ha-ras p21. These findings are discussed in relation to a possible cooperation or synergism between BKV and cellular oncogenes in human neoplasia.

Co-operation in cell transformation between BK virus and the human c-Harvey-ras oncogene.

Early-passage hamster embryo cells were transformed by recombinant DNA molecules containing BK virus (BKV) early-region gene and either the activated c-Ha-ras oncogene (pBK/c-rasA) or the normal c-Ha-ras proto-oncogene (pBK/c-rasN). The recombinant DNAs had a greater transforming ability and converted hamster cells to a more malignant phenotype than the single genes transfected separately. pBK/c-rasA was significantly more powerful than pBK/c-rasN in conferring to cells all the characteristics of transformation. Transfected DNA sequences were integrated mostly as single insertions into cellular DNA. Specific c-Ha-ras and BKV transcripts as well as c-Ha-ras p21 and BKV T antigen were detected in transformed cells. Although stimulation of c-Ha-ras expression by BKV enhancers cannot be excluded in recombinants, super-transfection and co-transfection experiments in hamster embryo cells and pre-neoplastic cell lines showed that BKV early-region and c-Ha-ras co-operate in transformation by contributing separate and independent functions.