Comparison of Interscalene Brachial Plexus Block Performed With and Without Steroids.

This prospective comparative clinical study was performed to evaluate the effect of triamcinolone when added to bupivacaine during brachial plexus blockade in patients undergoing shoulder surgery. Interscalene brachial plexus blocks were performed on 910 patients before shoulder surgery. Of the patients, 574 were randomly allocated to receive steroids added to the injected local anesthetic and 336 patients received local anesthetic without steroids. All patients were followed prospectively to evaluate the rate of successful anesthesia, duration of anesthesia, side effects of the block, adverse events, and persistent neurologic complications associated with interscalene brachial plexus block. Patients who received steroids had statistically longer pain relief than those who did not receive steroids (P<.001). No difference was found in adverse events, complications, or side effects. Compared with blocks performed without steroids, a statistically longer duration of block analgesia occurred with the addition of steroids to the local anesthetic solution during brachial plexus blockade. Rates of side effects, adverse events, and persistent neurologic complications were similar between the groups. [Orthopedics. 2016; 39(6):e1100-e1103.].

Subjective and functional outcomes following surgical repair of complete ruptures of the proximal hamstring complex.

Complete ruptures of the proximal hamstring tendon insertion are less common than typical muscle tendon junction strain injuries, with a far more debilitating natural history. The present study was designed to assess the subjective and functional outcomes of a group of patients following surgical repair of both acute and chronic complete proximal hamstring tendon ruptures. Twenty-five patients with an average age of 44 years comprised the study cohort. Clinical and diagnostic tests confirmed the diagnosis. All patients underwent primary repair of the tendon to the ischium with suture anchors and were protected postoperatively for 4 to 6 weeks. Following a progressively phased strengthening and functional exercise program, strength was isokinetically assessed. The Proximal Hamstring Injury Questionnaire was completed by all patients. All patients reported being satisfied with their outcomes following surgical repair. Strength scores for patients who were 6 months to <12 months (N=10) postoperative averaged an 87% (range, 69%-108%) strength return. Patients who were =or> 12 months postoperative (N=15) averaged a 98% strength return (range, 72%-176%). Patients sustaining a severe injury to the hamstring muscle caused by an external load should be suspected of having a proximal hamstring tendon disruption. Magnetic resonance imaging examination is necessary to confirm the diagnosis and assess the pathologic anatomy. Surgical repair of both acute and chronic cases yielded good results with a high degree of patient satisfaction and objective functional recovery.

Frequency of various tear patterns in full-thickness tears of the rotator cuff.

PURPOSE: We define specific rotator cuff tear patterns, prospectively document their occurrences, and emphasize the importance of tear pattern recognition during arthroscopy. METHODS: We prospectively analyzed 193 full-thickness rotator cuff tears intraoperatively from a single surgeon's practice. We address specific tear patterns, tear size, tissue mobility, tissue quality, and chronicity. RESULTS: Most of the tears were able to be categorized into 6 morphologic patterns. Of the tears, 3% could not be categorized. Appreciation of various rotator cuff tear patterns guided the positioning of bone and tissue sutures to achieve accurate apposition of tendon fibers. Transverse tears were the smallest and most common tear pattern, whereas tongue-shaped and U-shaped tears were larger patterns of comparable size. U-shaped tears had more retraction and less mobility and were of poorer tissue quality. Transverse tears were easily repaired, whereas U-shaped tears could not be repaired in 38% of cases (5/13). CONCLUSIONS: The quality and mobility of rotator cuff tissue were correlated with tear pattern, size, retraction, and chronicity. We describe a comprehensive rotator cuff tear classification scheme that encompasses 97% of all tears. Tear type was correlated with tendon retraction, tear size, cuff mobility, and tissue quality. On the basis of this information, the surgeon can anticipate tear patterns, which may improve pattern recognition and facilitate anatomic repair. LEVEL OF EVIDENCE: Level IV, prognostic case series.

A longitudinal study of patients with multidirectional instability of the shoulder with seven- to ten-year follow-up.

The purpose of our study was to evaluate the long-term outcomes of patients with multidirectional instability of the shoulder initially treated with rehabilitation exercises. Sixty-four patients were treated for atraumatic multidirectional instability of the shoulder between 1987 and 1990. Preliminary evaluation was performed 2 years after initiation of treatment, and final evaluation of the patients was performed at a mean of 8 years after initiation of treatment. At the preliminary evaluation, 5 patients were lost to follow-up. Of the remaining 59 patients, 20 had undergone surgical treatment for stabilization of their shoulder. Of the 39 nonsurgically treated patients, 19 continued to have significant pain, and 18 continued to have significant instability of their shoulder. Of the 59 patients, 28 subjectively rated their shoulder condition as better or much better after conservative treatment. At the final evaluation, 2 more patients were lost to follow-up, and 1 additional patient had had surgical treatment. Thus, of the 57 patients available for final follow-up, 36 had received nonsurgical care, and 21 had undergone surgical treatment. Of the 36 nonsurgically treated patients, 23 rated their shoulders as good or excellent with regard to pain, and 17 were good or excellent with regard to instability. By the modified Rowe grading scale, 5 of 36 patients had excellent results, and 12 had good results. The remaining 19 patients were rated as having poor results. Only 8 patients reported that their shoulders were free of all pain and instability. Overall, of the entire group of 57 patients evaluated between 7 and 10 years after initiation of care, 17 had a satisfactory outcome from nonsurgical management based on stability and Rowe scores, 23 had good or excellent results with regard to pain, and 20 subjectively rated their shoulders as good or excellent. This review revealed a relatively poor response to nonsurgical treatment of multidirectional instability in this population of young, athletic patients.

Measurement of baseline shoulder function in subjects receiving workers' compensation versus noncompensated subjects.

The purpose of this study was to ascertain whether a measurable difference existed in normative scores for the American Shoulder and Elbow Surgeons (ASES) questionnaire between subjects who had an active workers' compensation claim (WC) with no known shoulder injury and subjects without a compensation claim (non-WC). Subjects with non-shoulder-related orthopaedic injuries were recruited from a suburban orthopaedic sports medicine clinic and an urban occupational medicine clinic. They were asked to complete a composite questionnaire that consisted of demographic information and the ASES questionnaire. There were no significant differences in the ASES scores between subject groups. There were significant differences between subject groups with regard to work hours (P = .0001), work demands (P = .0001), and tobacco use (P = .0001). Subject group was also significantly associated with education level (P = .0001), marital status (P = .0001), work demands (P = .0001), gender (P = .0001), and sports participation (P = .0314). The ASES score was significantly affected by marital status (P = .0476), sports participation (P = .0008), and age (P = .0129).

The measurement of normative American Shoulder and Elbow Surgeons scores.

We determined baseline scores on the American Shoulder and Elbow Surgeons (ASES) questionnaire in individuals who had no known shoulder condition and evaluated related factors that could influence the score. A modified version of the questionnaire was completed by 343 patients from an outpatient orthopaedic center being seen for conditions unrelated to the shoulder. A separate group completed the questionnaire at two different times to assess its reliability. The mean ASES score was 92.2 +/- 14.5 points. The instrument was found to be very reliable (intraclass correlation coefficient = 0.96). Only the variables of shoulder status and sports participation entered the regression model to explain the variance in scores. Subjects aged 60 years or older exhibited decreased ability to lift above shoulder level and reach behind the back when compared with younger cohorts. Previous investigators have made the assumption that a normal preinjury ASES score is 100 points. This study raises questions about this assumption. This information can serve as a basis to compare normative scores with those of patients with active shoulder disease.

Surgical repair of complete proximal hamstring tendon rupture.

BACKGROUND: Complete proximal hamstring tendon rupture is a rare injury associated with significant functional loss. Nonoperative treatment has proven inadequate in returning patients to their previous activity level. PURPOSE: We wanted to describe the outcome of primary surgical repair of the proximal hamstring tendon avulsion. STUDY DESIGN: Retrospective cohort study. METHODS: Between 1994 and 1999, 11 patients (4 women and 7 men) with an average age of 41.5 years (range, 21 to 51) had a diagnosis of complete proximal hamstring tendon rupture based on mechanism of injury, physical examination, and radiographic assessment. All underwent a single operation followed by standard postoperative physical therapy. At the latest follow-up (average, 34 months), patients completed a questionnaire regarding such outcome parameters as pain, function, leg control, stiffness, return to activity, and overall satisfaction. RESULTS: Isokinetic muscle testing revealed an overall average of 91%return of hamstring muscle strength. Ten of 11 patients were satisfied with the result, and 7 of 9 athletically active patients were able to return to sport an average of 6 months (range, 3 to 10) after surgery. No difference between early and late repairs was identified in regard to functional outcome or return to sport. CONCLUSIONS: Satisfactory results can be achieved with both early and late hamstring tendon repairs in a majority of cases with surgical repair.