Revision arthroscopic capsulolabral reconstruction for recurrent instability of the shoulder.

We have investigated the outcome of arthroscopic revision surgery for recurrent instability of the shoulder after failed primary anterior stabilisation. We identified 40 patients with failed primary open or arthroscopic anterior stabilisation of the shoulder who had been treated by revision arthroscopic capsulolabral reconstruction and followed up for a mean of 36 months (12 to 87). There were 34 men and six women with a mean age of 33.1 years (15 to 48). Details of the patients, the technique of the primary procedure, the operative findings at revision and the clinical outcome were evaluated by reviewing the medical records, physical examination and the use of the Western Ontario shoulder instability index score, the American Shoulder and Elbow Surgeons score and the health status questionnaire 12. Recurrent instability persisted in four patients after the revision arthroscopic procedure. At the final follow-up, the mean American Shoulder and Elbow Surgeons score was 81.1 (17.5 to 99.5) and the mean Western Ontario shoulder instability index score was 68.2 (20 to 98.2). Quality-of-life scoring showed good to excellent results in most patients. Arthroscopic revision capsulolabral reconstruction can provide a satisfactory outcome in selected patients for recurrent instability of the shoulder provided that no large Hill-Sachs lesion is present.

Ipsilateral shoulder and elbow replacements: on the risk of periprosthetic fracture.

BACKGROUND: Ipsilateral shoulder and elbow replacements may leave only a short segment of bone bridging the two implants in the humerus. The potential for high stress concentrations as a result of this geometry has been a concern with regard to periprosthetic fracture, especially with osteoporotic bone. The study aims to determine the optimum length of the bone-bridge between shoulder and elbow humeral implants, and to assess the effect of filling the canal with cement. METHODS: A three-dimensional finite element model was used to compare the stresses between a humerus with a solitary prosthesis and a humerus with both proximal and distal cemented prostheses. The length of the bone-bridge and the effect of filling the canal with cement were studied under bending and torsion. FINDINGS: Gradual load transfer from prosthesis to bone was observed for all cases, and no stress concentration was evident. The length of the bone-bridge had no deleterious effect on stresses in the humerus, and filling the canal with cement did not appreciably decrease the loads carried by the humerus. INTERPRETATION: The length of the bone-bridge between stem tips has little effect on the resultant stresses in the humerus. Filling the canal with cement adds little benefit to the structural integrity of the humerus. Ipsilateral shoulder and elbow prostheses may be considered independent of one another in terms of risk of periprosthetic fracture.

An immunocytochemical analysis of torn rotator cuff tendon taken at the time of repair.

During rotator cuff repairs, it is recommended that the hypovascular tissue edge be resected. To investigate rotator cuff tendon histopathology, we performed immunohistochemistry on 8 surgical and 6 cadaveric specimens. Hoechst nuclear stain and standard hematoxylin-eosin were used for morphologic analysis. Antibody to human von Willebrand factor tagged with fluorescein isothiocyanate, conjugated, was used to visualize vascularity, and antibody to human procollagen type I tagged with Cy3 was used to visualize new procollagen synthesis. There were no significant differences in the vascularity of surgical specimens sectioned near the tear site (<2.5 mm from tear margin) and matched cadaveric controls. However, sections taken 2.5 to 5 mm away from the tear demonstrated more vessels than those taken from either control or surgical specimens within 2.5 mm of the tear (P <.001). There were no differences in nuclear distribution patterns or in procollagen production and distribution between surgical specimens from sites near the tear or away from the tear. On the basis of morphologic architecture, these data suggest that minimal debridement of tendon edges only is required to maximize healing of the rotator cuff tendon at the time of repair.

Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools?

BACKGROUND: Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. METHODS: The amount of time spent on musculoskeletal education at each of Canada's medical schools was reviewed by surveying the directors (or equivalents) of all sixteen undergraduate musculoskeletal programs. With use of data from this survey and the Association of American Medical Colleges' guide to curricula, the percentage of the total curriculum devoted to musculoskeletal education was determined. The prevalence of disorders related to the musculoskeletal system among patients of primary care physicians was determined on an international basis by reviewing the literature and on a local basis by surveying all primary care physicians affiliated with the University of British Columbia's Department of Family Medicine. RESULTS: The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. The questionnaires completed by the directors of the undergraduate programs indicated widespread dissatisfaction with the musculoskeletal education process and, specifically, with the amount of time devoted to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. CONCLUSION: There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.

Functional outcome of semiconstrained total elbow arthroplasty.

BACKGROUND: The objective of the present study was to review the results of primary total elbow arthroplasty with use of the Coonrad-Morrey prosthesis. Two hypotheses were tested: (1) the results in patients with inflammatory arthritis would be superior to those in patients with a traumatic or posttraumatic condition, and (2) the isometric extensor torque after total elbow arthroplasty would be significantly less than that of the contralateral elbow. METHODS: Forty-seven consecutive patients (fifty-one elbows) had the operation performed by one of three surgeons between November 1, 1989, and June 30, 1996. Thirty-six surviving patients (thirty-nine elbows) were available for follow-up. The mean duration (and standard deviation) of follow-up was 50 +/- 11 months (range, twenty-four to ninety-seven months). The mean age at the time of the operation was 64 +/- 11 years (range, twenty-seven to eighty-seven years). Eighteen patients (twenty-one elbows) had inflammatory arthritis. Eighteen patients (eighteen elbows) had an acute fracture or posttraumatic condition (posttraumatic osteoarthritis in eight, an acute fracture of the humerus in seven, nonunion of the distal aspect of the humerus in two, and primary osteoarthritis in one). The patients were evaluated with use of questionnaires (the Mayo elbow performance index, the Short Form-36 [SF-36], and the Disabilities of the Arm, Shoulder and Hand [DASH] Questionnaire); clinical examination by an orthopaedic surgeon who was not involved with the pre-operative, operative, postoperative, or follow-up care; radiographs; and elbow strength-testing with an isokinetic dynamometer. RESULTS: The mean score (and standard deviation) on the Mayo elbow performance index for the group that had inflammatory arthritis (90 +/- 11 points) was significantly higher than that for the group with a traumatic or posttraumatic condition (78 +/- 18 points) at the time of the latest follow-up (p < 0.05). In both groups, the mean extensor torque of the involved elbow was significantly less than that of the contralateral elbow (p < 0.05). No significant difference between the groups was found with respect to the flexion-extension arc of motion. Ten elbows (26 percent) had ulnar nerve dysfunction (a transient deficit in six and a permanent deficit in four); nine (23 percent), an intraoperative fracture (of the humeral diaphysis in four, of the ulnar diaphysis in four, and of the olecranon in one); three (8 percent), a periprosthetic infection; three, a triceps disruption; and one (3 percent), a revision because of a fracture of the ulnar component. There were no other revisions. Of the thirty-four elbows with complete radiographic follow-up, twenty-three had no change in the bone-cement interface. Progressive radiolucency was noted around the ulnar prosthesis in eight elbows, around the humeral prosthesis in one elbow, and around both components in two elbows. CONCLUSIONS: Patients who had a total elbow arthroplasty with use of a semiconstrained Coonrad-Morrey prosthesis were generally satisfied; the mean level of patient satisfaction was 9.2 of a possible 10 points for those who had inflammatory arthritis and 8.6 points for those who had a fracture or posttraumatic condition. The rates of complications involving the ulnar nerve, intraoperative fracture, triceps disruption, deep infection, and periprosthetic radiolucency are of concern.

Eccentric kinetic chain exercise as a conservative means of functionally rehabilitating chronic isolated insufficiency of the posterior cruciate ligament.

OBJECTIVE: To determine the efficacy of a home eccentric kinetic chain exercise program in improving isokinetic strength, knee function, and symtomatology in athletes with isolated posterior cruciate ligament (PCL) injury. DESIGN: Experimental design. SETTING: Allan McGavin Sports Medicine Centre, University of British Columbia, Vancouver, British Columbia, Canada. PARTICIPANTS: The study included 13 athletes with isolated PCL injury (n = 13) and 13 healthy sedentary subjects (n = 13). All participants were men and between 18 and 35 years of age. The group with isolated PCL injury all had been diagnosed at the Allan McGavin Sports Medicine Centre, all had been treated without surgery, and had been injured at least 6 months ago. Diagnosis was based on presentation of a positive posterior sag and posterior drawer. INTERVENTION: The group with isolated PCL injury (treatment group) underwent 12 weeks of eccentric kinetic chain exercise. The control group of healthy sedentary individuals did not undergo any form of rigorous training during the course of this study. Both groups were tested for isokinetic strength, knee function, and symptomatology at weeks 0, 6, and 12. Compliance was insured through frequent phone contact and progressive journal records of completion of daily exercise. Only those who completely executed the 12-week exercise program were included in the study. MAIN OUTCOME MEASURES: Hamstring and quadriceps isokinetic torque (Nm) at constant velocities of 60 and 120 degrees per second (degrees/s), Tegner Hop Test (meters), and Lysholm Knee Scale scores. RESULTS: A subject-versus-treatment data analysis clearly indicated significant increases in eccentric and concentric torque over the 12-week period in the treatment group. Tegner Hop Test and Lysholm Knee Scale scores also increased significantly after the eccentric squat exercise program. Quadriceps eccentric/concentric ratios at both testing velocities increased significantly after 12 weeks of rehabilitation. There were no significant differences in strength between extremities in the treatment group at any time during the course of this study. Before rehabilitation, there were no significant differences between eccentric and concentric torque values in either muscle group (quadriceps and hamstrings) of the treatment group. After the eccentric exercise program, the quadriceps in the injured extremity did exhibit significantly greater eccentric than concentric torque. The treatment group was significantly weaker than the control group in eccentric torque at both testing velocities at week 0. After the 12-week exercise program, however, there were no significant differences between groups in eccentric quadriceps strength. CONCLUSION: The results of this investigation support the eccentric squat program as a viable means of functionally rehabilitating chronic PCL insufficiency.

Addition of femoral 3-in-1 blockade to intra-articular ropivacaine 0.2% does not reduce analgesic requirements following arthroscopic knee surgery.

PURPOSE: To test the hypothesis that the addition of a preincisional femoral 3-in-1 block to intra-articular instillation with ropivacaine 0.2% at the end of surgery improves postoperative pain control in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) under general anesthesia. METHODS: In a prospective, randomized, placebo-controlled, double-blind trial, we studied 44 patients scheduled for inpatient ACLR. Prior to incision, the treatment group (n = 22) received a femoral 3-in-1 block with 40 ml ropivacaine 0.2%, augmented by infiltrations of the lateral and anteromedial incisions with 20 ml ropivacaine 0.2% at the end of the procedure. The control group (n = 22) received saline 0.9% instead of ropivacaine. All patients received an intra-articular instillation with 30 ml ropivacaine 0.2% at the end of surgery. The primary efficacy variable was 24 hr morphine consumption postoperatively standardized by weight, administered intravenously via a patient-controlled analgesia (PCA) pump. RESULTS: There was no difference between both groups in 24 hr PCA morphine consumption postoperatively (control, 0.45 +/- 0.44 [mean +/- SD] mg x kg(-1); treatment, 0.37 +/- 0.50 mg x kg(-1); p = 0.55). No difference was found in postoperative visual analog scale pain scores, adverse events, or vital signs. In the treatment group, R = 10/22 patients did not require postoperative morphine compared with R = 6/22 in the control group (P = 0.35). CONCLUSION: We found no effect of a femoral 3-in-1 block with ropivacaine 0.2% on postoperative analgesic consumption, compared to intra-articular instillation with ropivacaine 0.2% alone, in patients undergoing ACLR under general anesthesia.

The fate of meniscal tears after anterior cruciate ligament reconstruction.

OBJECTIVE: To investigate the incidence of meniscal pathology and subsequent treatment at an index arthroscopically assisted reconstruction of acute ACL tears (<3 weeks after injury) and to determine the outcome of meniscal pathology. DESIGN: Cohort study with average postoperative follow-up of 40 months (range, 24-76 months). SETTING: University-based sports medicine center. PATIENTS: Series of 162 patients admitted between January 1989 and July 1993. Follow-up was obtained for 105 patients. MAIN OUTCOME MEASURES: Initial presence, location, and treatment of meniscal tears. Subsequent surgery performed and further investigation or surgery being planned. RESULTS: Approximately 40% of patients had meniscal pathology at the index procedure. Most tears were in the lateral meniscus (34 of 45). All posterolateral tears and most other small tears were left untreated (25 of 45). Partial meniscectomies were performed on 17 large, complex, or radial tears that were not amenable to meniscal resuturing. Three meniscal repairs were performed on large, unstable tears. Most patients achieved good functional results. Of the five patients who required late meniscal surgery, three had normal menisci at the index procedure. The other two were asymptomatic until experiencing a reinjury. Despite ACL reconstruction in the acute phase, only two patients required treatment for postoperative arthrofibrosis. Three patients required revision ACL reconstruction after return to full activities and experiencing reinjuries. CONCLUSIONS: Stable tears of both lateral and medial menisci remain asymptomatic at 2 to 6 years' follow-up if treated conservatively. Those requiring further surgery had de novo tears or tears that were asymptomatic before reinjury. Although repair may be of benefit for large flap or bucket-handle tears, it does not appear necessary for most tears and may increase the incidence of postoperative stiffness.

Operative treatment of nonunion of surgical neck fractures of the humerus.

Seventeen patients who had undergone operative treatment for painful nonunion of a surgical neck fracture of the proximal humerus were evaluated an average of 6.3 years (range, 2-11 years) from the time of surgery to determine clinical and radiographic outcome. Ten patients underwent open reduction and internal fixation with tension band wiring and Rush rods, and 7 underwent proximal humeral hemiarthroplasty. The average age of the patients was 60 years old. After surgery, pain, function, and range of motion improved for both groups. University of California Los Angeles scores improved from an average of 4.4 to 22 points in the internal fixation group and from 4.8 to 21.4 in the hemiarthroplasty group. All 17 patients were eventually able to perform activities of daily living independently. No patient in either group was able to return to his or her preinjury level of work. Nonunion persisted in 2 patients who had undergone internal fixation, and avascular necrosis developed in 2 others. Eight of 10 patients in the internal fixation group required removal of the Rush rods for treatment of symptomatic mechanical impingement. Painful nonunion of a surgical neck fracture of the proximal humerus is a difficult problem to manage operatively. Pain relief and functional improvement was similar in patients who underwent either procedure. However, 11 of 17 patients had fair or poor ultimate outcomes.

Distraction arthroplasty of the elbow.

One of the most common and potentially disabling complications of elbow trauma is that of posttraumatic stiffness. The type of surgery best suited to the patient's need is a function of the existence of joint surface involvement (intrinsic or extrinsic). For intrinsic causes, distraction with or without interposition arthroplasty has altered functional outcome. What was thought to be a virtually untreatable complication has now been treated with an aggressive surgical release and distraction to achieve an acceptable result.

Biomechanical study of ligaments around the elbow joint.

The ligamentous contribution to elbow joint stability is a product of morphology and biologic parameters of each of the collateral ligaments. Better understanding of these characteristics is of paramount importance for successful ligament reconstruction in the surgery for joint replacement and traumatic injury. Two experiments were performed. In the first, the arc of elbow flexion where the individual ligament was either taut or slack was measured; in the second, the structural properties of each collateral ligament were determined by using bone-ligament-bone preparations. The anterior medial collateral ligament (AMCL) and radial collateral ligament (RCL) were taut throughout most of the entire arc of flexion. The posterior medial collateral ligament (PMCL) was taut only when the elbow was in a flexed position. Among the collateral ligaments, the AMCL was the strongest and stiffest with an average failure load of 260 N. The palmaris longus tendon, the most frequently used graft for elbow ligament reconstruction, was similar in strength (357 N).

Treatment of scaphoid nonunion by radical curettage, trapezoidal iliac crest bone graft, and internal fixation with a Herbert screw.

Ten adult male patients with scaphoid nonunions were treated by radical curettage, trapezoidal iliac crest bone grafting, and internal fixation with a Herbert screw. The mean patient age was 24.7 years, and the mean duration of the nonunion before surgery was 37.3 months. Mean follow-up time was 30.4 months. Nine of the ten nonunions healed, although one patient required a second bone-grafting procedure. The mean postoperative grip strength was 45.0 kg, and the mean postoperative pinch strength was 11.5 kg. The mean postoperative range of motion was volar flexion, 76.1 degrees; dorsiflexion, 74.2 degrees; radial deviation, 22.1 degrees; and ulnar deviation, 40.1 degrees. The scapholunate angle decreased from a mean of 72.8 degrees preoperatively to 60.6 degrees postoperatively (p less than 0.025). The mean carpal index was 0.57 postoperatively. Mean scaphoid length increased postoperatively and was within 0.2 mm of the opposite (normal) scaphoid in every patient except the single patient with a persistent nonunion (p less than 0.025). All patients returned to work (eight as laborers), and nine of ten wrists were subjectively rated as good or excellent. The results of the series suggests that treatment of displaced scaphoid nonunion by radical curettage, trapezoidal iliac crest bone grafting, and internal fixation with a Herbert screw is an effective method of treatment that reconstitutes scaphoid anatomy and promotes excellent wrist function.

Medial epicondylitis caused by injury to the medial antebrachial cutaneous nerve: a case report.

A 35-year-old man who had chronic elbow pain due to medial epicondylitis received a steroid injection into the medial epicondyle. This was followed immediately by increased pain and symptoms of dysesthesia in the distribution of the medial antebrachial cutaneous nerve. On surgical exploration 9 months later, the nerve was found to lie directly over the medial epicondyle and appeared to have sustained an injection injury. This report draws attention to the fact that because the posterior division of the medial antebrachial cutaneous nerve may lie directly over the medial epicondyle, it may be at risk of direct injury if injections are given into the epicondyle.

Comparative functional analysis of the Bristow, Magnuson-Stack, and Putti-Platt procedures for recurrent dislocation of the shoulder.

Literature on anterior shoulder instability deals most often with elimination of recurrence following reconstruction. We analyzed the subjective function, loss of motion and shoulder strength of three operative procedures: Magnuson-Stack, Bristow, and Putti-Platt. A retrospective review of 27 patients, 9 in each surgical group, with no postoperative dislocations or on-going pain was performed. All patients were male, right hand dominant with the right shoulder affected. Average time of followup was 6.75 years (range, 4.2 to 10.3 years). All patients completed a questionnaire and had their range of motion measured by a hand-held goniometer and their shoulder strength tested on the Cybex II Dynomometer. Peak torque as a percent of body weight and side-to-side differences were calculated for six arm positions and compared to nine right hand dominant controls of similar age and recreational activity. Sixty percent returned to throwing sport. One Magnuson-Stack and Bristow patient felt full functional return to preinjury level. Three patients in each of these two groups returned to unmodified throwing sport whereas no Putti-Platt patient attained this level. Deficit of external rotation at shoulder neutral measured 4.7 degrees, Magnuson-Stack; 12.2 degrees, Bristow; and 21.8 degrees, Putti-Platt. At 90 degrees shoulder abduction, similar deficits in external rotation measured 6.4 degrees, 11.6 degrees, and 28.8 degrees respectively. These values were statistically significant employing analysis of variance. We compared the operative groups as a whole to the controls and compared the operative groups to each other.(ABSTRACT TRUNCATED AT 250 WORDS)

The patient with symptomatic chronic anterior cruciate ligament insufficiency. Results of minimal arthroscopic surgery and rehabilitation.

Forty-nine patients with 51 chronic symptomatic anterior cruciate deficient knees were studied retrospectively by chart review and follow-up examination an average of 5.8 years postinjury and 1.5 years from arthroscopic evaluation, with or without arthroscopic surgery, and the institution of a conservative rehabilitation program. Subjective evaluation of function was obtained by questionnaire. At arthroscopy, meniscal lesions were seen in 37 of 51 knees, and degenerative changes were noted in 24 knees. The ACL was absent in 43 knees. Partial meniscectomy or suturing was performed on 20 patients. All patients had an average of 3 weeks of supervised physical therapy stressing hamstring strengthening. At followup, thigh girth measurements of injured and normal legs found thigh wasting in 40 patients. Seven of 33 patients radiographed showed evidence of degenerative changes. About two-thirds of the patients returned to some level of athletics and had no problems with activities of daily living. Twenty were able to return to pivoting sports, but only five could return to their preinjury levels of competition. Of the 18 patients who did not return to athletics, only 8 were considering or had had a ligament reconstruction. Those patients who chose to continue rehabilitation beyond the prescribed period and who modified their activities had a better functional outcome.

Swimming injuries of the knee, foot and ankle, elbow, and back.

The practitioner need not be an expert in swimming but should understand the rudiments of the stroke and training techniques such patients are subjected to. This will aid in proper identification and analysis of the problem. The solution may require the resources of physician, therapist, coach, and parent as well as swimmer.