Diagnosis of biceps tendon dislocation by kinematic magnetic resonance imaging.

Biceps tendon dislocation is an uncommon condition that may be overlooked due to its association with more common shoulder pathology. Diagnosis may be further obscured by the difficulty of palpating the biceps tendon in a muscular or obese patient. We present a patient with a dislocating biceps tendon in which the diagnosis was confirmed by kinematic MRI.

Surgical management of soft tissue lesions associated with pelvic ring injury.

Mortality rates associated with pelvic ring injury combined with open wounds have decreased considerably during the past 2 decades. Consequently, increased survivability has heightened the demand for definitive stabilization techniques to address pelvic ring instability. Control of hemorrhage and avoidance of sepsis remain paramount concerns in the initial and later stages of management, respectively. Exclusion of occult and readily apparent perforations of the genital urinary and gastrointestinal tracts is essential when using a multidisciplinary approach. Recognition of open and closed degloving injury patterns and appropriate adherence to treatment guidelines will optimize outcome and avoid catastrophic complication.

Diastasis of bipartite sesamoids of the first metatarsophalangeal joint.

Injury to the metatarsophalangeal (MP) joint of the great toe, often termed "turf-toe", is a common occurrence in football. We have identified four cases of first MP plantar capsular injury with diastasis of a bipartite sesamoid. In three cases, observation and protection resulted in progressive widening of the fragments associated with pain and disability. These players required resection of the distal sesamoid fragment and repair of the volar capsule. The fourth player underwent acute repair of the medial retinaculum and capsule. All players have had a full return to sports activity. Diastasis of components of a partite sesamoid provides objective evidence of disruption of the plantar capsular mechanism. Early recognition of this condition confirmed by stress radiographs is recommended. Treatment may include early protection followed by resection, if painful, or acute repair of the retinaculum. Previous descriptions of turf-toe have not included injuries to the sesamoid complex of the first MP joint. In our opinion, the term turf-toe should represent the consequences of a hyperextension injury to the first MP joint in which the volar capsule has been disrupted proximal to the sesamoid. A classification for first MP joint injuries is presented.

A comparison of patient-controlled analgesia and continuous lumbar plexus block after anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) reconstruction is often a painful operation. Fifty-eight patients who underwent ACL reconstruction using patellar tendon autograft received either a lumbar plexus block (LPB) or patient-controlled analgesia (PCA) for pain relief during the first 24 h after surgery. The average total dose of narcotic used was dramatically less for the LPB group (10.1 mg) than for the PCA group (91.9 mg). The common narcotic analgesic side effects of nausea, pruritus, sedation, and urinary retention were significantly less in the LPB group. The LPB is a safe and effective alternative analgesia after ACL reconstruction.

The Ellison iliotibial-band transfer for a torn anterior cruciate ligament of the knee. Long-term follow-up.

We studied the long-term results of the Ellison technique of extra-articular transfer of the iliotibial band, without advancement of the biceps tendon, as the sole operative treatment for a torn anterior cruciate ligament. Thirty-two patients (thirty-two knees) were evaluated an average of eleven years (range, seven to fifteen years) after the operation. The average age at the time of the operation was twenty-two years (range, sixteen to thirty-four years). Eighteen patients (56 per cent) had a modified Lysholm score of less than 84 points, indicating symptoms during the activities of daily living. Only six patients (19 per cent) had a subjectively normal knee (a modified Lysholm score of more than 94 points). The most common reason for a poor subjective score was the presence of symptoms of instability, in twenty-four patients (75 per cent). Twenty-four patients (75 per cent) had a positive pivot-shift test and twenty-nine patients (91 per cent), a positive Lachman test. Twelve patients (38 per cent) had severe (grade 3 or 4) radiographic changes. The radiographs of the knee appeared normal (grade 0) in only eight patients (25 per cent). There was a significant association between a meniscal injury and radiographic changes (p < 0.05). Fourteen patients (44 per cent) had subsequent procedures due to persistent instability or pathological changes in the articular cartilage or in a meniscus. There was a significant decline in the subjective and objective knee scores in the twenty-one patients who were evaluated at both two and eleven years. The number of patients who had a positive pivot-shift test increased from five (24 per cent) to sixteen (76 per cent). Subjectively, the number of patients who had a good result decreased from fourteen (67 per cent) to five (24 per cent). Objectively, nine patients (43 per cent) had a rating of good at two years; this fell to three (14 per cent) at eleven years. Symptomatic instability, pain, and a positive pivot-shift test were the most common reasons for a poor result. Because of the decline in the subjective and objective scores, we no longer recommend the Ellison procedure as the sole operative treatment for a torn anterior cruciate ligament of the knee.

Glenoid dysplasia. A case report and review of the literature.

Glenoid dysplasia is a rare congenital abnormality that may be associated with vague shoulder pain, limitation of motion, and weakness of the upper extremity. In many cases it is an incidental finding on chest roentgenogram, and high-level function is usually possible before the onset of symptoms or degenerative changes. The case of an 18-year-old collegiate football offensive lineman who developed symptoms secondary to previously undetected bilateral glenoid dysplasia is reported. Roentgenograms demonstrated dysplastic scapular necks, and arthrography showed a deformed, constricted shoulder capsule. Magnetic resonance imaging defined the extent of the cartilaginous anlage, and arthroscopy demonstrated progressive articular cartilage degeneration. Although treatment alleviated the shoulder symptoms at low-level activities, the patient was unable to successfully compete under the extreme demands of an American football lineman.

Open and arthroscopic synovectomy in hemophilic arthropathy of the knee.

Open and arthroscopic synovectomies of the knee in patients with classic hemophilia were evaluated with regard to effectiveness in reducing bleeding episodes, the effect on range of motion (ROM), and roentgenographic progression of hemophilic arthropathy. Eleven patients underwent 13 synovectomies (eight open, five arthroscopic). The average follow-up periods were 7.9 years and 2.2 years for the open and arthroscopic groups, respectively. Both procedures significantly reduced recurrent hemarthroses. Knee ROM in the open synovectomy group was decreased or unchanged in 75% and minimally increased in 25%, whereas there was an increased in 80% and a decrease in 20% of the knees in the arthroscopic group. Furthermore, 62.5% of the knees required manipulation to improve ROM in the open synovectomy group, versus 0% in the arthroscopic group. Hemophilic arthropathy progressed in most knees in both groups. The arthroscopic group had a longer operative procedure (122 versus 59 minutes), but required less hospitalization (9.4 versus 23.1 days) and 25.6% less Factor VIII replacement. Both techniques reduce hemarthroses. There is usually a net loss of ROM with the open versus a net gain with the arthroscopic procedure, and roentgenographic progression hemophilic arthropathy is slowed but not halted after synovectomy.

Fibular stress fracture associated with distal tibiofibular synostosis in an athlete. A case report and literature review.

A 19-year-old collegiate football player with progressive ankle syndesmosis ossification developed acute localized fibular tenderness. Roentgenograms demonstrated a fibular stress fracture proximal to the superior extent of the ossific mass. Surgical resection of the mass resulted in uneventful fibular healing, with resolution of acute and chronic symptoms.

Repair of peripheral meniscal tears: open versus arthroscopic technique.

Tears in the peripheral vascular zone of 71 menisci in 68 knees were repaired by us from 1978 to 1986. The meniscus repair was done by open arthrotomy in 26 cases and by arthroscopic techniques in 45 cases. We have assessed the relative efficacies of open and arthroscopic repair techniques. The results were compared in knees with and without anterior cruciate laxity. The indications for meniscal repair included unstable peripheral detachments and longitudinal tears of the outer third of the meniscus. Open repair was performed by a posteromedial arthrotomy incision. Arthroscopic repair was done using the double-lumen guide system with a limited posterior incision for retrieval of needles. We have found that the arthroscopic technique is easier to perform than the open repair because some tears are too far inside the rim to lend themselves to open suture. The average follow-up is 4 years, 2 months, with a range of 2-10 years. There have been no neurologic or vascular injuries from either technique. Twenty-five patients have had a repeat arthroscopy. The overall failure rate was 9.8%. The difference between the failure rate of 11% in the open-repair group and 8.8% in the arthroscopic repair group was not statistically significant. The failure rate in anterior cruciate-stable knees was 8% versus a 13% failure in cruciate-deficient knees. We conclude that both open and arthroscopic meniscus repair techniques are safe and effective with few complications in both stable and unstable knees. Anterior cruciate ligament stability is ideal, but it is not mandatory for a successful result.

Meniscus repair in the anterior cruciate deficient knee.

From 1979 to 1986, isolated repair of a peripheral vascular zone meniscal tear was performed in 22 patients (23 menisci) who had ACL insufficiency. For various reasons none of these patients underwent repair or reconstruction of their ACL. The meniscus repair was done by open arthrotomy in 12 cases and by arthroscopic techniques in 11 cases. The purpose of this study was to evaluate the success rate of a meniscal repair in an anterior cruciate deficient knee. The average age of the patients at the time of surgery was 25 years and the average followup was 56 months. Six patients (26%) had mild occasional pain not requiring medication and one patient had moderate pain requiring nonnarcotic pain medication. Eight patients (26%) had occasional giving way episodes and one of them underwent ACL reconstruction 5 years later because of frequent giving way. One patient required a postoperative manipulation for inadequate range of motion, but there were no neurovascular injuries or infections. There were three patients (13%) who had failed repairs or a retear and required subsequent subtotal meniscectomies. None of the other patients had any clinical symptoms or signs of a meniscal tear. There were no significant differences between the results of open or arthroscopic repair. Even though the failure rate of meniscus repair may be greater in an unstable knee, we conclude that meniscus repair is not contraindicated in an anterior cruciate deficient knee.

Isolated avulsion of the biceps femoris insertion. A case report.

The clinical, roentgenographic, and operative findings of an isolated biceps femoris avulsion in a 21-year-old man demonstrated the significance of the static stabilizers about the knee, menisci, and articular cartilage. Examination of the dynamic structures about the knee, however, may present a diagnostic problem. A systematic examination of the musculature (hamstrings, quadriceps, and patellofemoral mechanism) should be included in the evaluation of every acute knee injury. Special attention should be given to the surface anatomy as well as function of the knee.

Arthroscopy update #7. Alternative arthroscopic techniques for meniscus repair. A review.

Several treatment options and surgical techniques have evolved for treating vascular zone tears of the meniscus. The rationale and indications for meniscus repair are discussed, and a review of the various arthroscopic meniscal repair techniques is presented.

Isolated fracture of the coronoid process of the ulna: a case report and review of the literature.

A rare case of a fracture involving almost the entire coronoid process of the ulna (type III) is described. Open reduction and internal fixation of this fragment restored elbow stability and resulted in a painless range of motion lacking only 5 degrees of extension at 7 months.

Supracondylar fracture of the femur following total knee arthroplasty.

Three supracondylar femur fractures above total knee arthroplasties in two patients were treated with a Brooker-Wills intramedullary locking nail. All three fractures healed while preserving nearly all of the prefracture range of motion. The nail provides stable internal fixation with good control of rotation and allows early range of motion. The technique can be considered if the fracture is at least 8 cm proximal to the joint line.

TLSO treatment of idiopathic scoliosis. An analysis of the Wilmington jacket.

A retrospective study of one hundred female patients treated for idiopathic scoliosis using an underarm plastic thoracolumbar-sacral orthosis (TLSO) jacket was undertaken. The purpose of the study was to evaluate the efficacy of the Wilmington jacket, to search for clinical variables which could statistically predict success, and to evaluate preliminary results of parttime bracing in 25 patients. The following parameters were statistically evaluated by multiple regression analysis: age, sex, curve location, number of vertebrae in curve, Cobb angle, maturity (Risser sign, menarche), curve flexibility, and hours in the jacket. The overall success rate was 81%, and onset of menarche and Risser sign were statistically significant prognostic variables. Ten patients (10%) underwent posterior spinal fusion for curve progression. Bracing with an underarm scoliosis jacket is a successful method of treatment of idiopathic scoliosis in the immature spine. We do not recommend brace treatment for postmenarchal patients or patients with a Risser sign of Grade 1 or greater until curve progression has been observed. Furthermore, the Wilmington jacket appears to give similar results for part-time brace wearers.

Treatment of femoral shaft fractures with the Brooker-Wills interlocking intramedullary nail.

Fifty femur fractures were treated with the Brooker-Wills intramedullary locking nail. The indications included subtrochanteric, subisthmal, segmental or comminuted acute fractures or nonunions, and intramedullary shortening procedures. Eighteen technical problems in 13 (26%) patients were encountered during insertion of the nail. The incidence of technical problems was high early in the series and in procedures done with the patient in the supine position. Adverse clinical results from technical errors occurred in two patients. Most technical errors seem avoidable with careful technique. The mean healing time was only 12.1 weeks and there were four nonunions (8%). One patient had a 10 degrees malunion, four patients had 1-2 cm of shortening, and there were two late device fractures. No patients had rotational malalignment or deep infections. The results and complication rate are comparable to those reported for other interlocking systems. The Brooker-Wills nail is useful for treatment of complex femur fractures and has been effective in preventing malrotation, angulation, and excessive shortening.

Induction chemotherapy in advanced head and neck cancer. A Radiation Therapy Oncology Group Study.

Cisplatin (cis-platinum, 100 mg/m2) and fluorouracil (1000 mg/m2/d), for 120 hours' infusion every three weeks for three courses, produced a 93% overall response rate and a 54% complete clinical response at the single-institution level. The same combination was tested in the Radiation Therapy Oncology Group to evaluate the effectiveness and feasibility of this combination. An overall response rate of 86% was obtained, with a 38% complete clinical response. Only 27 of 42 patients completed planned surgery. Compliance with chemotherapy and radiation therapy was substantially better. No additional morbidity after surgical resection or postoperative radiation therapy was identified as secondary to the induction chemotherapy. We conclude that the combination of cisplatin and fluorouracil infusion is effective, with high complete clinical response rate in patients with advanced, previously untreated head and neck carcinoma.

Total hip arthroplasty complicated by mismatched implant sizes. Report of two cases.

Numerous alternative types and sizes of implants for total hip arthroplasties are currently available. Two cases are reported in which the head size of the femoral component inserted was larger than the corresponding inner diameter of the acetabular cup. These are the first reported cases of this technical complication. The error can be avoided with careful preoperative planning and proper selection of implants. At 12- and 30-month follow-up evaluation, however, neither of these hips had dislocated or required revision. Immediate revision is not recommended, unless the hip dislocates or has symptomatic subluxations.