Partial-thickness tears involving the rotator cable lead to abnormal glenohumeral kinematics.

HYPOTHESIS: The objective of this study was to determine the biomechanical function of the rotator cable when a partial-thickness (>50%) tear is present. We compared intact specimens with partial tears of the anterior cable followed by partial anterior and posterior tears in regard to glenohumeral kinematics and translation. The hypothesis was that partial-thickness tears will lead to abnormal glenohumeral biomechanics, including glenohumeral translation and path of glenohumeral articulation. METHODS: Five fresh frozen cadaveric shoulders with intact labrum, rotator cuff, and humerus were tested using a custom shoulder testing system in the scapular plane. Glenohumeral translation was measured after applying an anterior load of 30 N at different angles of external rotation. The path of glenohumeral articulation was measured by calculating the humeral head center with respect to the glenoid articular surface at 30°, 60°, 90°, and 120° of external rotation. RESULTS: With an anterior force of 30 N, there was a significant increase in anterior and total translation at 30° of external rotation after the anterior cable was cut (P < .05). When the tear was extended to the posterior cable, there was a significant increase in anterior, inferior, and total translation at 30° and 120° of external rotation (P < .05). With respect to the path of glenohumeral articulation , the humeral head apex was shifted superiorly at 90° and 120° of external rotation after the posterior cable was cut (P < .05). CONCLUSION: Partial-thickness articular-sided rotator cuff tears with a thickness >50% involving the rotator cable increased glenohumeral translation and changed kinematics in our cadaveric biomechanical model.

Considerations in Evaluating Treatment Options for Patellofemoral Cartilage Pathology.

Patellofemoral (PF) pain, a subset of anterior knee pain, presents a particularly challenging diagnosis due to the multifactorial etiology. Within this group, assigning the patient's symptoms to a patellofemoral cartilage lesion is indirect; that is, a diagnosis by exclusion as hyaline cartilage is aneural. In addition, these PF compartment lesions are often in conjunction with various comorbidities, for example, malalignment and/or instability. In light of these factors and the high shear and compression stresses at the PF compartment, patellar and trochlear chondral lesions require unique treatment considerations from the tibiofemoral compartments. A thorough understanding of the various cartilage restoration techniques available is necessary to select the best option for the individual patient/knee/lesion noting that there is overlap of techniques' applications. In addition, failure to address and correct associated comorbidities may jeopardize the outcome of any cartilage restoration procedure. That is, the key to achieving optimal outcomes with PF cartilage restoration is to select the best cartilage treatment for the particular setting and to concomitantly optimize the PF biomechanical environment and stability.

Surgical treatment for osteochondritis dessicans of the knee.

Osteochondritis dissecans (OCD) of the knee is a disease of the subchondral bone with secondary injury to the overlying articular cartilage. OCD lesions are generally categorized as juvenile-growth plates open-or adult-growth plates closed. This maturity-based classification scheme has a prognostic value in that many juvenile OCD lesions will heal with conservative care while most symptomatic adult OCD lesions need surgical intervention. OCD can result in pain, knee joint effusions, loose body formation, and arthritis. Short-term treatment goals include pain and symptom resolution while the long-term goal is to minimize arthritis. Surgical options include debridement, drilling, microfracture, reduction and fixation, autograft osteochondral transplantation, autologous chondrocyte implantation, and allograft osteochondreal transplantation.

Toe tourniquet syndrome caused by cable tie.

BACKGROUND: Tourniquet syndrome clinically presents as pain, discoloration, paresthesias, and swelling distal to a constricting band. If left untreated or unrecognized, it may induce ischemia, resulting in tissue necrosis or auto amputation of the appendage. Treatment involves removal of all constricting bands and monitoring of the neurovascular status of the digit after constriction removal. RESULTS: A healthy 7-year-old female had tied a cable tie around her toe for an unknown amount of time before evaluation. After examination of the toe and concern for ischemia, the cable tie was removed. Once the cable tie was removed, the area of necrotic tissue at the dorsal proximal phalanx was gently debrided taking special care to avoid the extensor tendon, which was exposed but appeared to be intact. Tetanus prophylaxis was updated, she was sent home on oral antibiotics and she went home with dressing changes. The patient was referred for a psychiatric consultation due to the unique nature of the self-injury and concern for possible underlying disorder. CONCLUSIONS: This case is the first in the literature to describe toe tourniquet syndrome caused by a cable tie. This case highlights the importance of treatment of the offending structure with release and to monitor the digit for signs of ischemia. A thorough history should be sought from both the patient and, in this case, the patient's caregiver to seek any additional clues of depression, anxiety, or anger. If warranted, appropriate consultation of a psychiatrist may be warranted.

Factors affecting return to play after anterior cruciate ligament reconstruction: a review of the current literature.

Anterior cruciate ligament reconstruction has been reported to produce normal or near-normal knee results in > 90% of patients. A recent meta-analysis suggested that, despite normal or near-normal knees, many athletes do not return to sports. Rates and timing of return to competitive athletics are quite variable depending on the graft type, the age of the patient, the sport, and the level of play. Even when athletes do return to play, often they do not return to their previous level. Graft failure, subjective physical factors, and psychological factors, including fear of reinjury and lack of motivation, appear to play a large role in patients' ability to return to sporting activities.

Klein line on the anteroposterior radiograph is not a sensitive diagnostic radiologic test for slipped capital femoral epiphysis.

OBJECTIVE: To correlate the amount of slipped capital femoral epiphysis (SCFE) that results in an abnormality of the Klein line. In mild slips, the Klein line on the anteroposterior (AP) radiograph may remain normal, potentially leading to a delay in diagnosis and emphasizing the importance of obtaining a frog lateral radiograph in patients with a suspected SCFE. STUDY DESIGN: A retrospective review of 55 patients with SCFE was performed from January 2004-March 2009. Of the 55 patients, 32 were missing radiographs and were excluded, leaving 23. The 23 sets of radiographs were reviewed. RESULTS: Of the 23 hips studied with SCFE, only 9 (39%) were able to be diagnosed on the AP radiograph using the classic definition of the Klein line. Twenty cases (87%) of SCFE were identified on the AP radiograph using the modified Klein line. All 23 cases (100%) of SCFE were identified on frog lateral radiographs. CONCLUSIONS: Relying on the Klein line will fail to identify many mild or moderate slips. An AP and a frog lateral pelvic radiograph should be obtained in any child when an SCFE is suspected to accurately identify the disorder and to prevent delays in diagnosis.

Adductor pollicis longus strain in a professional baseball player: case report and review of thenar pain.

Thenar pain can represent a significant morbidity for a baseball player who relies on manual dexterity for gripping a bat and precise and accurate throws. While osseous, ligamentous, and neurovascular pathologies are commonly considered, musculotendinous injuries are often neglected in the differential diagnosis of thenar pain. We present a case of adductor pollicis longus strain as a cause of acute thenar pain in a baseball player. Adductor pollicis longus strains should be considered in any baseball player sustaining a hyperabduction force to the thumb.

Locked knee caused by lateral meniscal capsular disruption: verification by magnetic resonance imaging and arthroscopy.

Locking of the knee is commonly reported in patients presenting to an orthopedic surgeon. This case report describes a rare cause of knee locking: subluxation of the lateral meniscus without an associated tear. This case highlights the importance of the popliteus recess in stability of the lateral meniscus. Injury to this area may lead to meniscal subluxation and knee locking.

Medicine versus orthopaedic service for hospital management of hip fractures.

BACKGROUND: Hospital care of patients with hip fractures often is managed primarily by either a medicine or orthopaedic service, depending on the institution. Whether complication rates, length of stay, or time to surgery differs on different services is unknown. QUESTIONS/PURPOSES: We therefore determined whether (1) perioperative complication rates, and (2) length of stay and time to surgery for patients undergoing surgical management of hip fractures differed by the specialty of the primary service. PATIENTS AND METHODS: We performed a retrospective cohort study at a university-based academic hospital of patients undergoing surgery for hip fracture admitted to medicine and orthopaedic services during 2006. Of the 98 patients included in the analysis, 34% were managed by a medicine service and 66% by orthopaedics. Using multivariable regression models to adjust for patient characteristics and comorbidities, we determined whether service designation predicted the likelihood of severe or intermediate perioperative complications, length of stay, or time to surgery. RESULTS: The rate of severe or intermediate complications for patients undergoing surgical management of hip fractures was 30%. Patients with medicine or orthopaedic services did not differ in the rate of severe or intermediate complications or length of stay in adjusted analysis. However, time to surgery was longer in patients managed by the medical service in adjusted analysis. CONCLUSIONS: In our patient cohort, the likelihood of perioperative complications occurring among patients with hip fractures did not differ by service designation in adjusted analysis. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.