Biceps tendinitis and subluxation.

Since the 17th century, the long head of the biceps tendon as a source of shoulder pain and its functional significance has been a source of debate. Although the term tendinitis is commonly used, overuse tendon injuries infrequently demonstrate inflammatory cells; instead, degenerative changes resulting from the failure of self-repair usually are found. Bicipital tendinitis or bicipital tenosynovitis is most often secondary to impingement beneath the coracoacromical arch. Primary bicipital tendinitis and tendinitis secondary to instability are possible, however. Through a careful history, physical examination, and appropriate imaging studies, the clinician can establish the diagnosis of disorders of the biceps tendon Arthroscopic evaluation greatly improves the diagnosis and treatment of biceps tendon and related shoulder pathology. Although the exact functional role of the biceps tendon remains incompletely defined, a growing body of evidence supports its role as a stabilizer of the glenohumeral joint. This stabilizing function should be incorporated into the treatment of biceps tendon disorders. Routine tenodesis has been replaced by a more individualized approach, taking into consideration physiologic age, activity level, expectations, and exact shoulder pathology present. New repair techniques are under development, and preservation of the biceps-labral complex is now preferred when possible.

Pathophysiology of anterior shoulder instability.

OBJECTIVE: To review some of the important biomechanical factors that provide glenohumeral stability, along with the pathologic mechanisms involved in glenohumeral instability of the shoulder. DATA SOURCES: Current English medical literature concerning the multiple pathologic factors involved in glenohumeral instability was reviewed. DATA SYNTHESIS: Multiple dynamic and static factors control glenohumeral instability. Knowledge of normal shoulder anatomy and biomechanics is necessary to interpret pathologic events. CONCLUSIONS/RECOMMENDATIONS: Dynamic and static factors collectively provide stability to the glenohumeral joint. Disruption or malfunction of these factors causes dysfunction in the shoulder.

Nonunion of the fractured clavicle: evaluation, etiology, and treatment.

Although often viewed as benign injuries, clavicular fractures can lead to complications, particularly nonunions. The nonunion rate has been reported to be between 0.1% and 15%. Contributing factors to nonunion include severe initial trauma, marked initial displacement and shortening, soft tissue interposition, primary open reduction and internal fixation, refracture, open fracture, polytrauma, and inadequate initial immobilization. A clavicular nonunion is rarely asymptomatic and often results in disability from pain at the site of nonunion, altered shoulder mechanics, or a compression lesion involving the underlying brachial plexus or vascular structures. Treatment options include nonsurgical management, salvage procedures, and reconstructive procedures. The present goal is to obtain union with reconstructive procedures. The fixation methods described range from external fixation to plate and screw osteosynthesis. We prefer open reduction and internal fixation with plates and screws and with intercalary tricorticocancellous grafts to obtain union and restore the clavicle to its normal length.

Acromioclavicular joint injuries.

Acromioclavicular joint injuries, including sprains and dislocations, are common shoulder problems treated by orthopaedic surgeons. The classification of acromioclavicular joint injuries comprises six grades, according to the degree of ligamentous disruption and displacement. Grades I and II are generally treated nonoperatively, whereas types IV, V, and VI are treated surgically. Treatment for grade III injuries remains controversial. Fractures of the distal aspect of the clavicle have been divided into three types. Type I fractures are stable and require brief immobilization. Type II fractures are unstable and require surgical fixation. Type III fractures often require late surgery for acromioclavicular arthritis.

The Bridle procedure: a new treatment for equinus and equinovarus deformities in children.

The Bridle procedure is a tritendon anastomosis between the posterior tibialis, anterior tibialis, and peroneus longus, combined with an Achilles tendon lengthening for treating equinus and equinovarus deformities. The technique avoids problems of tendon attachment to bone and tendon placement for balance. One hundred seven procedures were performed on patients with cerebral palsy with 74% excellent and good results overall. The average follow-up was 5 years 9 months. The procedure was also performed with mixed results, on smaller groups of patients with other neuromuscular diseases.

Prosthetic replacement in acute fractures of the proximal humerus.

The surgical treatment of selected displaced fractures of the proximal humerus with a humeral head prosthesis is a challenging procedure. Adequate knowledge of the pertinent anatomy and biomechanics of the shoulder as well as a clear roentgenographic evaluation of the displaced fracture patterns are essential. Successful prosthetic replacement requires adherence to technical factors involving soft tissue mobilization, prosthetic insertion, and tuberosity repair. Also, it is important to have a closely supervised rehabilitation program to achieve early passive motion and strengthening after fracture healing.

Comparative mechanical analysis of a looped-suture tendon repair.

The in vitro breaking force of a braided nylon looped-suture tendon juncture designed to decrease tying time was compared with the breaking force of the modified Kessler and Bunnell techniques. Repaired with either braided nylon or tetrafluoroethylene, porcine digiti quarti propius tendons were tested to single cycle failure on a MTS hydraulic testing machine. The results showed that the looped-suture technique had a mean breaking force that was statistically indistinguishable from that of the Bunnell technique regardless of suture material. However, the breaking forces for the looped suture and Bunnell techniques were statistically greater for both suture materials when compared with the modified Kessler technique. The resistance to gap formation for the looped suture was found to be intermediate between the Bunnell technique and the modified Kessler technique.

Surgical reconstruction of chronic anteromedial rotatory instability of knee. A review with computer analysis of 149 cases.

The clinical records were reviewed of 142 men and 7 women (average age 26.8 years; range, 15 to 58 years) who had surgical reconstruction for anteromedial rotatory instability of the knee. All were treated consecutively at the same clinic during a 15-year period (1960 to 1975). Preoperative and postoperative symptoms were rated both subjectively and objectively by devised scales and analyzed by a computer program. Comparison of the three major surgical procedures show that the subjective success rate was 87% for the pes anserinus transfer, 70% for the posterior oblique ligament reconstruction, and 72% for the combination procedure. Of the 149 patients, 130 had been injured in sportive activities and 110 were able to return to some degree of athletics. Accurate and detailed recording of clinical data allowed construction of subjective and objective rating systems for computer analysis in review of a large series over a period of years. This approach enhanced our ability to obtain correlation and objective evaluation of the data. Commercial equipment for evaluating the quadriceps and hamstrings is beneficial in determining that a patient has achieved complete rehabilitation or if there will be a permanent decrease in function after surgical intervention.