Grade III acromioclavicular joint injury in Australian Rules Football.

We have reviewed fourteen Australian Rules Football players who were seen consecutively by a single surgeon with grade III acromioclavicular joint injuries between January 1993-June 1997. After discussion at initial consultation eight players elected for non-operative management and six for operative management. Two players in the non-operative group subsequently underwent surgical reconstruction after failure of non-operative treatment. The mean return time to non-contact training was 2.4 weeks (range 1-4, S.D. 1.52) in the non-operative group and 6.3 weeks (range 3.5-10, S.D. 2.99) in the operative group. However return to sports specific training (contact training) was at a mean of 20.8 weeks (range 10-32. S.D. 8.56) in the non-operative group and 13.6 weeks (range 6-24. S.D. 7.06) in the operative group. Return to competitive football matches for the non-operative group was at a mean of 26.2 weeks (range 10-34,S.D. 8.84) and 18.8 weeks (9.5-28. S.D. 8.05) for those treated operatively. These results were not statistically significant. At final follow up the subjective scores for the current overall condition of the shoulder when compared to the uninjured side, were 72.5 (range 20-100, S:D.24.9) for the non operative group and 87.3 (range 75-100, S:D.10.61) for the operative group and this difference was also not statistically significant. Conclusions in this study are limited by small numbers and lack of statistically significant results. The results show a trend towards faster return to ARF and a more satisfactory outcome for patients undergoing surgery compared to their non operative cohorts.

Arthroscopic repair of glenolabral injuries with an absorbable fixation device.

In view of potential problems with metallic implants around the shoulder a bioabsorbable tact has been used in arthroscopic repair of labral lesions in the shoulder joint. We report on a consecutive series of 70 patients (71 shoulders) who had arthroscopic stabilization of Bankart lesions, SLAP lesions, and other labral detachments with the Suretac device. Minimum follow-up time was 12 months (range 12 to 27 months). Clinical outcome was assessed with the Constant score. The recurrence of dislocation or subluxation in the 42 unstable shoulders was 12% (5 of 42), and in 78% (33 of 42) the Constant score was rated good or excellent. The recurrence of dislocation in true anteroinferior dislocators was 3.2% (1 of 31). A total of 82.3% (14 of 17) of patients with SLAP repairs were rated good or excellent, and 53% (9 of 17) returned to their preinjury level of sporting activities. Eight (67%) of 12 patients with labral detachments other than Bankart and SLAP lesions were rated good or excellent, and 64% (7 of 11) returned fully to sports.

Results of interfascicular nerve grafting for radial nerve lesions.

During the 10 year interval 1979-1989, 20 patients underwent nerve grafting of a radial nerve lesion, 13 high radial and 7 posterior interosseous. Average follow-up was 38 months (range 12 months-10 years). Overall 72% of patients achieved a Highet Scale rating of M3 or better function and 44% M4 or better recovery. Age of the patient and length of the nerve graft did not seem to influence outcome. Time from initial injury to nerve grafting did affect outcome, with 85% of patients grafted within 6 months obtaining M3 or better recovery. No patient grafted 12 months after injury recovered any useful function. Lesions of the posterior interosseous nerve had a consistently superior recovery. Power grip strength in the affected hand of patients averaged 60% of the unaffected hand while key pinch averaged 74%. There was good correlation between the Highet Scale rating of recovery and the ultimate power grip or key pinch strength obtained. Hand dexterity, as assessed by the turning and displacing tests of the Minnesota Rate of Manipulation Test, displayed a wide range of scores in both affected and unaffected hands. Nevertheless, a relative score derived from the results obtained in the displacing test did show correlation with the Highet Scale rating. All patients with M4 or better recovery obtained relative scores for the affected hand that were in the middle of the range of scores considered an average performance for a normal population. Patients who achieved M4 or better nerve recovery following radial nerve grafting also obtained a functional hand as evidenced by the results of grip, key pinch strength, and hand dexterity testing. Lesser degrees of recovery were accompanied by poorer strength and dexterity ratings reflecting inferior function.

Arthroscopic treatment of adhesive capsulitis.

Although conservative management with or without manipulation performed with the patient under anesthesia is the generally accepted treatment strategy for adhesive capsulitis, considerable interest is being shown in arthroscopic surgical procedures for this disorder. This study reviews the outcome of patients who underwent an arthroscopic release of the inferior capsule, reproducing in a controlled fashion the traumatic disruption of the inferior capsule commonly caused by manipulation with the patient under anesthesia. The outcome of 24 patients (26 shoulders) was assessed with an average follow-up of 13.5 months. A total of 88% of patients were very satisfied with the procedure, and no operative complications occurred. A return to normal or near normal shoulder function in 76% or more of the study group for forward flexion, abduction, and external rotation was demonstrated. A total of 50% of patients still had some restriction in internal rotation. The Constant Scoring system, also used to assess clinical shoulder function, revealed 87% of patients had achieved an excellent or good result when compared with the contralateral normal shoulder score. Our results suggest that arthroscopic capsular release is a safe and effective treatment for adhesive capsulitis, with patterns of recovery that compare favorably to other treatment modalities.

Cutaneous nerve lesions of the shoulder and arm after arthroscopic shoulder surgery.

Increasing use of shoulder arthroscopy has caused developing awareness of the associated complications. A consecutive series of patients who had undergone arthroscopic surgery of the shoulder was reviewed. The overall incidence of a sensory deficit was 21 (7%) in 304 patients at 2 weeks after operation, and in approximately half (3.3%) of these patients this condition was still present at 8 months' average follow-up. These deficits fell into three distinct patterns, suggesting that damage was occurring to three different nerve branches. Most of these areas of hypesthesia corresponded to lesions of cutaneous branches of the axillary nerve; the most likely cause was direct injury at the portal sites, particularly the lateral portal.

Results after replantation and revascularization in the upper extremity in children.

The rates of survival of the amputated part and the functional outcomes were studied retrospectively after seventy-three replantations and eighty-nine revascularizations in the upper extremity in 120 children. All operations were performed between January 1974 and December 1988 after partial and complete amputations at various levels. The ages of the patients ranged from three days to sixteen years. The average duration of follow-up was thirty-six months (range, fourteen months to seven years) for the patients who had had a replantation and thirty months (range, fourteen months to eight years) for the patients who had had a revascularization. The rate of survival of the amputated part was significantly higher (p < 0.0002) after revascularization (seventy-eight parts [88 per cent]) than after replantation (forty-six parts [63 per cent]). There was no association, for either group, between survival and the preoperative duration of ischemia, the level of the injury, the digit that had been injured, the number of arteries that had been repaired, or the use of venous grafts. The rate of survival after replantation of completely amputated parts was 72 per cent (twenty-eight of thirty-nine parts) when the amputation had resulted from a laceration injury and 53 per cent (eighteen of thirty-four parts) when the amputation had resulted from a crush or an avulsion injury. The rate of survival after revascularization of incompletely amputated parts was 100 per cent (all forty-five parts) when the injury had been the result of a laceration and 75 per cent (thirty-three of forty-four parts) when it had been the result of a crush or an avulsion. We did not find any relationship between the age of the patient and the rate of survival of the amputated part after revascularization; however, there was a significantly higher rate of survival (p , 0.02) after replantation in children who were less than nine years old (77 per cent [twenty-four of thirty-one parts]) compared with the rate in those who were nine to sixteen years old (52 per cent [twenty-two of forty-two parts]). The viability of the digit was in jeopardy after twenty-nine (40 per cent) of the seventy-three replantations and nineteen (21 per cent) of the eighty-nine revascularizations. Immediate reoperation resulted in the salvage of only two of the twenty-one replanted parts and six of the twelve revascularized parts that had a reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)

Adverse reactions to an absorbable shoulder fixation device.

Bioabsorbable implants have been advocated for use in repair of a torn glenoid labrum to correct shoulder instability. These implants have been thought to be safe and to have little toxicity, antigenicity, or adverse side effects. However, similar implants have been shown to cause nonspecific granulomatous reactions when implanted into bone or soft tissues in studies in both animals and human beings. This article reports the adverse effects of these implants in six shoulders of five patients who had repair of a damaged glenoid labrum. All patients reported increasing pain and loss of shoulder motion after insertion of these devices. All required a further arthroscopic lavage and debridement to reduce the inlracapsular synovitis. Granulomatous reactions were identified histologically in all cases. No long-term side effects were encountered, and all patients recovered satisfactorily.

Femoral head allograft bone banking.

Prior to 1986, there was no uniform protocol for the collection, storage and safe transfer of allograft bone in South Australia. A programme was instituted that resulted in the collection of 100 femoral heads, of which 46 heads were used for a variety of orthopaedic procedures in 31 patients. Wastage was high with 46 femoral heads being discarded because of infection or failure to adhere to all aspects of the protocol. The donor population was found to be a safe source of bone with no cases of unsuspected hepatitis, syphilis, human immunodeficiency virus, or malignancy being detected. There was no infection in recipients. By observing strict criteria for the acceptance of donor bone and aided by a diligent clerical service, this type of allograft can provide a way of dealing with extensive bone deficiency in a number of surgical settings.

The value of a new ultrasound stress test in assessment and treatment of clinically detected hip instability.

Fifty patients with clinical suspicion of hip dislocation were investigated prospectively with a dynamic ultrasound stress test. A posterior force was applied to hips in flexion and any movement between the femoral head and the acetabulum was measured. The results of this test showed that posterior movement ranged from 0 to 13.0 mm. Hips that were clinically normal had a mean movement of 1.4 mm, hips with minor clinical instability had a mean movement of 0.6 mm, hips with moderate instability had a mean movement of 4.5 mm, and those with major instability had a mean movement of 5.1 mm. This was statistically significant to a 1% confidence interval. We propose two groups of ultrasound-detected movement: group A less than 5.0 mm representing physiologic laxity, and group B greater than or equal to 5.0 mm being pathological and requiring treatment.