Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically.

The purpose of this study was to examine longitudinally the natural history of asymptomatic rotator cuff tears over a 5-year period and to assess the risk for development of symptoms and tear progression. Since 1985 through the present, bilateral sonograms were done on all patients. A review of consecutive sonograms done from 1989 to 1994 revealed 58 potential patients with unilateral symptoms who had contralateral asymptomatic rotator cuff tears. Of these 58 patients, 45 (22 men, 23 women) responded to a comprehensive questionnaire and 23 additionally returned for examination and repeat sonographic evaluation. The questionnaire was based on the American Shoulder and Elbow Surgeons score and included several outcome-based questions. A physical examination was performed in a standardized fashion along American Shoulder and Elbow Surgeons guidelines. Repeat high-resolution sonograms were performed by a single experienced radiologist. Primary and repeat sonograms were then reassessed for tear size and location by two independent experienced radiologists blinded to the clinical data results. Twenty-three (51%) of the previously asymptomatic patients became symptomatic over a mean of 2.8 years. The average Activities of Daily Living score for those remaining asymptomatic was 28.5 of 30 and for those becoming newly symptomatic, 22.9 of 30 (P <.5). The mean visual analog pain score (1 = no pain) for those remaining asymptomatic was 1.1 and for the newly symptomatic patients, 4.0. Of the 23 patients who returned for ultrasound, 9 were asymptomatic and 14 symptomatic. Only 2 of the 9 patients remaining asymptomatic had progression of their tears. Overall, 9 of 23 patients had tear progression. No patient had a decrease in the size of the tear. Our results demonstrate that symptoms can develop in patients with previously asymptomatic rotator cuff tears when seen in the context of a contralateral symptomatic tear. Development of symptoms was associated with a significant increase in pain and decrease in the ability to perform activities of daily living (P <.05). There appears to be a risk for tear size progression over time.

The effects of a pneumatic tourniquet on blood loss in total knee arthroplasty.

OBJECTIVE: In lower-extremity surgery there are significant risks associated with the use of tourniquets. This prospective study was done to assess to what extent these risks may be offset by the potential advantages of tourniquets, namely reductions in blood loss, length of hospital stay and complication rates. DESIGN: A prospective case study. SETTING: A major urban hospital. PATIENTS: Sixty-three consecutive patients scheduled for primary cemented total knee arthroplasty (TKA) were blindly randomized into tourniqet (n = 33) and non-tourniquet (n = 30) groups. INTERVENTION: TKA during which a pneumatic tourniquet was applied or not applied to control blood loss. MAIN OUTCOME MEASURES: Perioperative blood loss, operating time, complication rates, hospital stay and transfusion needs. RESULTS: Differences in the total measured blood loss, intraoperative blood loss and the Hemovac drainage blood loss between the 2 groups were not significantly different (p > 0.25). The calculated total blood loss was actually lower in the non-tourniquet group (p = 0.02). Between the groups there were no statistical differences in surgical time, length of hospital stay, transfusion requirements or rate of complications (although there was a trend to more complications in the tourniquet group (p = 0.06)). CONCLUSION: The effectiveness of a pneumatic tourniquet to control blood loss in TKA is questionable.

A new provocative test for carpal tunnel syndrome. Assessment of wrist flexion and nerve compression.

To establish the value of median nerve compression with wrist flexion as a provocative test for carpal tunnel syndrome (CTS), we performed a prospective study of 64 patients (95 hands) with CTS confirmed by electrodiagnostic studies and 50 normal subjects (96 hands). We recorded results for the common provocative tests (Tinel's percussion test, Phalen's wrist flexion test and the carpal compression test) and the new test which combines wrist flexion with median nerve compression. Using a receiver operator characteristic curve (ROC) technique, we found that the optimal cut-off time for the wrist-flexion and median-nerve compression test was 20 s, giving a sensitivity of 82% and a specificity of 99%. These results were significantly better than for Phalen's wrist flexion test (61% and 83%, respectively) and for the sensitivity of Tinel's test (74%). The positive predictive values of the wrist flexion and median-nerve compression test, which is more important clinically, were 99%, 95% and 81% at population prevalences of 50%, 20% and 5%, respectively. These were significantly better than those of the three other provocative tests at each prevalence. Electrodiagnostic studies have significant false-positive and false-negative rates in CTS, and therefore provocative tests remain important in its diagnosis. We have shown that wrist flexion combined with the median-nerve compression test at 20 s, is significantly better than the other methods, and may thus be clinically useful.

Flexor digitorum profundus tendon-to-bone repair: an ex vivo biomechanical analysis of 3 pullout suture techniques.

Avulsions or distal transsections of the flexor digitorum profundus tendon are typically repaired by direct suture of tendon to the distal phalanx. The tensile properties of tendon-tobone repairs performed in cadaver fingers using 3 common suture patterns, the Bunnell, the Kessler, and the Kleinert techniques, were compared; 3-0 Prolene (monofilament) suture was used. Repairs done using the Kessler pattern had an average yield force of 30 N, compared to 39 N for the Bunnell and Kleinert patterns. Although these average yield forces were greater than that required for active digital flexion, considerable elongation (average, 8 mm) was measured at a force of 20 N. Data indicated that the safety factor achieved with these repair methods is lower than that achieved with modern tendon-to-tendon repair methods. The authors conclude that the common tendon-to-bone repair techniques are insufficient to withstand the higher forces associated with controlled passive and active motion rehabilitation methods that are currently advocated.

Cubital tunnel syndrome and the painful upper extremity.

Cubital tunnel syndrome is the second-most-common compressive neuropathy. With the increasing prevalence of entrapment neuropathies, the presentation of ulnar nerve compression with a painful upper extremity appears to be more common. Although our knowledge and understanding of this disease are increasing, the principles of management remain constant. We are obliged to reach a timely and appropriate diagnosis to minimize the extent of neurologic injury and institute an appropriate treatment regimen to preserve and restore normal neural function. Although there are many ways to reach these goals, the avoidance of complications is paramount to achieve a reliable and pain-free outcome. Preventing injury to the medial antebrachial cutaneous nerve, complete release of all sites of compression, and avoidance of creating new compressive sites are the keys to this end.

High median nerve entrapments. An obscure cause of upper-extremity pain.

Compression of the median nerve at the wrist is the most common nerve entrapment syndrome but may be over- or misdiagnosed. With high (proximal) median nerve entrapment being uncommon and having an elusive diagnosis, proximal compression may be overlooked as a cause of the painful upper extremity. Recognition and diagnosis of this problem will help ensure timely and effective management of the more common pain syndromes.