Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries.

We retrospectively studied 17 cases of distal pectoralis major muscle rupture to compare the results of repair in acute and chronic injuries and to compare operative and nonoperative treatment. Thirteen patients underwent surgery (six acute injuries [less than 2 weeks after injury] and seven chronic injuries) and four had nonoperative management. The mean age of the patients at injury was 29, and 10 of the 17 injuries were the result of weight lifting. Follow-up ranged from 18 months to 6 years (mean, 28 months). All patients subjectively rated strength, pain, motion, function with strenuous sporting activities, cosmesis, and overall satisfaction. Objectively, patients were examined for range of motion, deformity, atrophy, and strength. Isokinetic strength testing was performed in eight patients: six treated operatively (three acute and three chronic) and two treated nonoperatively. Overall subjective ratings were 96% in the acute group, 93% in the chronic group, and only 51% in the nonoperative group. Isokinetic testing showed that patients operated on for acute injuries had the highest adduction strength (102% of the opposite side) compared with patients with chronic injuries (94%) or nonoperative treatment (71%). There were no statistically significant subjective or objective differences in outcome between the patients treated operatively for acute or chronic injuries, but these patients fared significantly better than patients treated nonoperatively.

Fasciotomy for exertional anterior compartment syndrome: is lateral compartment release necessary?

The standard surgery for exertional anterior compartment syndrome is fasciotomy of the anterior and lateral compartments of the leg. We prospectively studied the necessity of lateral compartment release, which can add morbidity and extend recovery. We performed 30 anterior compartment releases in 20 patients (10 bilateral operations) with exertional anterior compartment syndrome but not lateral compartment involvement. We alternately performed only an anterior compartment release or both anterior and lateral compartment releases on 10 patients. The 10 patients who underwent bilateral surgery each had, during the same surgery, an anterior and lateral compartment release on one leg and only an anterior compartment release on the other. All were athletes involved in running sports. Overall, satisfactory outcomes were seen in 90% of the limbs--93% (14 of 15) that had anterior compartment release and 87% (13 of 15) that had release of both compartments (no statistically significant difference). For the patients who had unilateral surgery, the average time for full return to sports was 8.1 weeks after anterior release only and 11.4 weeks after release of both compartments, a statistically significant difference. The average time for full return to sports after bilateral surgery was 12.1 weeks. Among these patients, seven said that the leg with only anterior release seemed to recover faster. We concluded that when doing a fasciotomy for exertional anterior compartment syndrome alone, a lateral compartment release is not necessary.

Exertional compartment syndromes of the lower extremity.

Compartment syndromes may be acute or chronic secondary to exertion or exercise. The chronic or exertional type most commonly involves the lower extremity, particularly the anterior compartment of the lower leg, and is the subject of this review. Rarely, an exertional compartment syndrome may become acute. The diagnosis is based on history, physical examination, and compartment pressure measurements. The differential diagnosis of exertional leg pain includes stress fractures, stress reaction, periostitis, claudication, popliteal artery entrapment, and peripheral nerve entrapment. Unusual causes, such as a ganglion of the proximal tibiofibular joint causing an anterior compartment syndrome, have recently been reported.

Surgical management of Achilles tendon overuse injuries. A long-term follow-up study.

We studied 79 cases of surgically treated Achilles tendon overuse injuries in 66 patients. Fifty-three (80%) of these patients were competitive or serious recreational runners operated on between 1978 and 1991. There were 49 men and 17 women with a mean age of 33 years (range, 17 to 59). The cases were divided into surgical subgroups based on their site of primary symptoms and abnormalities: paratenonitis (23), tendinosis (partial rupture or degeneration) (15), retrocalcaneal bursitis (24), insertional tendinitis (7), and combined abnormalities (10). Followup included a comprehensive patient questionnaire and office examination. There were 79% satisfactory (51% excellent, 28% good) and 21% unsatisfactory (17% fair, 4% poor) results. The percentages of satisfactory results in the paratenonitis group (87%) were best and those in the tendinosis group were the worst (67%). Satisfactory results were obtained in 75% of the patients with retrocalcaneal bursitis and 86% with insertional tendinitis. Seven of the 45 cases with longer than 5-year followup with initially satisfactory results deteriorated with time and required reoperation (16%). Of these, 4 were in the tendinosis group, 2 had retrocalcaneal bursitis, and 1 had paratenonitis. One of the 34 patients followed less than 5 years required reoperation.

Chronic exertional compartment syndrome of the lower leg.

This review focuses on the clinical history, diagnosis, and treatment of chronic exertional compartment syndrome (CECS) of the lower leg. Measurement of muscle compartment pressures, the most conclusive way to confirm the diagnosis, may yield significantly elevated values in CECS patients compared to normal controls. It is important to recognize that medial tibial syndrome is a distinct clinical entity from deep posterior CECS. Once a diagnosis of CECS is established, surgical decompression of the involved compartment is recommended. For as yet unknown reasons, the results of fasciotomy are almost always satisfactory in the anterior compartment and significantly less so in the posterior compartment.

Surgical management of exertional compartment syndrome of the lower leg. Long-term followup.

Forty-six limbs in 28 patients were surgically treated for exertional compartment syndrome. One group of 16 patients (26 limbs) underwent a fasciotomy for exertional anterior compartment syndrome (Group 1). A second group of 12 patients (20 limbs) underwent a fasciotomy for exertional deep posterior compartment syndrome (Group 2). Patients in Group 2 experienced symptoms for a significantly longer time than those in Group 1:16 versus 6.8 months (P < 0.01). All three of the pressure measurements used in this study (resting pressure, 1 minute after exercise, and 5 minutes after exercise) were significantly higher in both groups than in normal controls (P < 0.01). The 1 minute after exercise values were significantly higher in Group 1 (mean, 36.5) than in Group 2 (mean, 29.1) (P < 0.01). In Group 1, 25 of 26 limbs (96%) had excellent results. In Group 2, 13 of 20 limbs (65%) had satisfactory results (5 excellent and 8 good) and 7 (35%) had unsatisfactory results (4 fair and 3 poor). Those patients who had an unsatisfactory outcome did so within 6 months. Patients in Group 1 had a significantly higher rate of satisfactory results than those in Group 2 (P < 0.05).

The role of arthroscopy in the assessment and treatment of tibial plateau fractures.

This retrospective study compared arthroscopic treatment of certain tibial plateau fractures to traditional open techniques. From January 1989 through August 1992, 40 patients with tibial plateau fractures were evaluated. After reviewing the records and radiologic studies, 23 patients were included in the study based on fracture patterns. Using Hohl's revised classification system, patients with either local compression or split compression fractures were included. Twelve of these patients were treated with arthroscopic reduction and percutaneous fixation (ARPF; group A). The remaining 11 underwent open reduction and internal fixation (ORIF; group B). The results of the ARPF group were superior to those of the ORIF group. In the ARPF group, all reductions were anatomic and remained fixed at least 3 months postoperatively, whereas only six (55%) of the ORIF patients had anatomic reductions initially. Furthermore, one of these patients had further loss of reduction on follow-up radiographs. Iliac crest bone graft was used in two patients in group A and 10 in group B. The use of bone graft in the arthroscopically treated group had no effect on the final outcome. The average length of postoperative hospitalization for the ARPF patients with isolated tibial plateau fractures was 5.36 days compared with 10.27 days for patients who were treated with ORIF. Average time to full weight bearing was 8.95 weeks in the ARPF group and 12.30 weeks in the ORIF group. No patients in either group had medial collateral ligament repairs. No ARPF-treated patients experienced valgus laxity after treatment. One patient in the ORIF group had residual instability and another walked with a cane.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results of surgical management of Achilles tendinitis in runners.

Achilles tendinitis is a common occurrence in long-distance runners. Although most respond well to conservative therapy, there are some who require operative intervention. The short-term results of surgical treatment are good, with a success rate more than 85%. The authors present nine successful long-term results in runners. However, in two of the runners who continued to compete and train at long distances, symptoms recurred. Reoperations were performed to permit successful running careers for five and nine years. Runners resumed their careers after the second operation by supervised training and long-distance, competitive activities.

Electrical stimulation of the thigh muscles after reconstruction of the anterior cruciate ligament. Effects of electrically elicited contraction of the quadriceps femoris and hamstring muscles on gait and on strength of the thigh muscles.

The effects of neuromuscular electrical stimulation on the strength of the thigh muscles and on gait were examined in ten patients after reconstruction of the anterior cruciate ligament. The patients were randomly assigned to one of two treatment groups: neuromuscular electrical stimulation and volitional exercise, or volitional exercise alone. A four-week course of electrically elicited co-contraction of the thigh muscles resulted in significant attenuation of the characteristic loss of strength of the quadriceps as compared with volitional exercise. There was no significant difference between groups in any measure of performance of the hamstring muscles. In the group that received neuromuscular electrical stimulation, the values for cadence, walking velocity, stance time of the involved limb, and flexion-excursion of the knee during stance were significantly different from those of the volitional exercise group. Flexion-excursion of the knee during stance was directly and significantly correlated with strength of the quadriceps femoris muscle. Flexion of the knee during stance was qualitatively different in the involved extremity as compared with the uninvolved extremity in all patients. There is a rapid flexion of the knee at weight acceptance that is maintained throughout stance and probably reflects stabilization of the joint by muscular coactivation to compensate for weakness of the quadriceps. The patients who received neuromuscular electrical stimulation had stronger quadriceps muscles and more normal gait patterns than those in the volitional exercise group.

Plantar fasciitis. Etiology, treatment, surgical results, and review of the literature.

Plantar fasciitis is a common orthopedic syndrome among athletes and nonathletes. The etiology of the pain is multifactorial but usually involves inflammation and degeneration of the plantar fascia origin. The majority of patients will respond to conservative measures. Surgical treatment is reserved for those patients who do not respond. A complete plantar fascia release is performed through a medial longitudinal incision. Prominent heel spurs and degenerated areas in the plantar fascia are resected. Of 27 surgically treated cases followed from one to three years, satisfactory results were obtained in 24 cases. Histologically, localized fibrosis or granulomatous changes or both were noted in several cases.

Prosthetic materials for anterior cruciate ligament reconstruction.

Reconstruction of the anterior cruciate ligament (ACL)-deficient knee has been a major focus in sportsmedicine research over the past 20 years. The need for functional stability for patients with symptomatic instability, especially if they participate in pivoting or jumping sports, as well as the potential for development of precocious arthritis in the ACL-deficient knee, has led to the use of intra-articular autogenous reconstruction from multiple tissue sources. The most popular method of reconstruction involves the central one third of the patellar tendon with attached bone blocks from the patella and tibial tubercle; this remains the "gold standard" to which other reconstructions are compared. Other common tissue sources are the semi-tendinosus, gracilis, and fascia lata, utilized in a number of varied techniques. Although the initial strength of these various autografts has been more than adequate to withstand the stresses of various activities, autogenous tissue transplants undergo degeneration in a hostile synovial environment. Butler et al have shown that the original strength of patellar tendon grafts in primates declines approximately 15% within six weeks. The original strength sometimes fails to fully return, and there seems to be great variability in healing and revascularization of autogenous tissue. Furthermore, autogenous transplants require the sacrifice of a tendon or ligament with a biologic function. In other instances, autogenous tissue may not be available or easily sacrificed, most commonly secondary to a previous autogenous reconstruction that has failed. Over the last decade, there have consequently been extensive laboratory studies as well as clinical trials of various prosthetic materials.

Surgical management of Achilles tendinitis.

Inflammation of the Achilles tendon and its contiguous structures is one of the most common overuse problems seen in runners. There are actually several etiologies. Involvement of the tendon itself is secondary to areas of mucinoid or fibrotic degeneration, or may be a result of a partial rupture. The sheath (or mesotenon) may also become chronically inflammed. Retrocalcaneal bursitis seems to be a separate entity with hypertrophy and fibrosis of the bursa usually occurring in conjunction with a prominent posterior superior angle of the os calcis. The vast majority of patients can be successfully treated nonoperatively; however, there is a group of patients who are refractory to nonoperative management who would like to continue running, particularly if they are competitive. A retrospective review of 45 surgical cases in 37 patients was performed. All but two of these patients were competitive long-distance runners. There were 24 cases of Achilles tendinitis and/or tenosynovitis, 14 cases with retrocalcaneal bursitis, and 7 with a combination of both. Mean followup was 3 years (range, 1 1/2 to 8 years). Overall there were 87% satisfactory results. Ninety-two percent of the patients with involvement with the tendon and/or sheath had a satisfactory outcome as compared with 71% of patients with retrocalcaneal bursitis. Passive dorsiflexion in the 29 unilateral cases improved from a mean of 17 degrees preoperatively to a mean of 25 degrees postoperatively. We feel that surgery offers a solution for highly motivated runners with chronic posterior heel pain who would like to continue running when conservative measures have failed.

Ulnar nerve compression by heterotopic ossification in a head-injured patient.

Although heterotopic ossification (HO) at the elbow is a frequent occurrence following head injury, nerve compression by heterotopic bone is quite rare. We report the case of a 22-year-old woman with head injury and well-documented HO at the left elbow who developed signs and symptoms of an ulnar neuropathy four months after her original injury. Electrodiagnostic studies confirmed the presence of a severe ulnar nerve lesion at the level of the elbow. Anterior transposition of the left ulnar nerve showed the nerve to have been compressed by heterotopic bone.

Shoulder pain.

Disabling shoulder pain is common in those who engage in athletic activities and there is a wide spectrum of causes. Some entities are secondary to an acute injury such as a shoulder subluxation or dislocation with subsequent disability. More commonly, we see pain resulting from repeated insult, such as chronic tendinitis or attritional tears of the rotator cuff. Each entity has its own distinctive characteristics, so that a thorough history, physical examination, radiograms, and, occasionally, special studies should result in the proper diagnosis. The appropriate treatment can then be instituted, minimizing the period of disability as well as preventing future morbidity.