Biomedical subjects
Publications and source records attributed to D W Altchek.
There are two technical aspects of ACL reconstructive surgery that always present some difficulty. One is determining how much notchplasty is sufficient prior to passage of the graft. The other is passing the suture leader of the graft through the tibial and femoral bone tunnels. We have used a plastic disposable Yankauer suction tip to facilitate both of these tasks.
Shoulder arthroscopy is most commonly performed in some variation of the lateral decubitus position with the arm in traction. Because of reports of neuropraxia associated with the traction, we have investigated the use of the "beachchair" or sitting position for shoulder arthroscopy. We have used this position for over 50 consecutive patients for arthroscopic debridements, arthroscopic subacromial decompressions, and arthroscopic shoulder stabilizations.
Thirty-two patients (64 hips) in whom avascular necrosis (AVN) of the femoral heads was highly suspected clinically were studied by magnetic resonance (MR) imaging, radionuclide bone scintigraphy, and conventional radiography. MR studies were positive for AVN in 37 hips, compared with 30 positive scintigraphic studies. In all cases in which scintigraphy and radiography were positive, MR imaging demonstrated decreased signal from the affected femoral heads, indicative of bone marrow disease. Imaging results were confirmed by biopsy or subsequent imaging appearances. In patients with negative initial scintigraphic and radiographic studies, the MR imaging criterion for a positive study was a moderately decreased bone marrow signal displaying segmental patterns within an otherwise normal-appearing femoral head on relatively T1-weighted images. In this series of high-risk patients, radionuclide scintigraphy had a sensitivity of 81%, compared with 100% for MR imaging. MR imaging should be the imaging modality of choice for early evaluation of bone marrow changes indicative of AVN.
Arthroscopic acromioplasty has become a common procedure for the treatment of chronic impingement syndrome. Short-term studies have consistently shown good results; however, long-term data have not previously been reported in the literature. Of 102 consecutive patients undergoing arthroscopic acromioplasty at our institution from 1984 to 1988, 82 patients (83 shoulders) were available for evaluation. The patients were reviewed after a mean of 8 years, 5 months from their original surgery. There were 16 failures (19%) with unsatisfactory results following surgery; 13 patients (15%) required further surgery to relieve persistent pain. Thirty-three percent of all patients previously involved in sports were unable to return to overhead and throwing sports due to pain and lack of power with throwing. Overall, 81% of patients in our series had good to excellent results after 6 to 10 years. To optimize the indications for the procedure, other causes of impingement, such as occult instability and degenerative joint disease, should be ruled out. Throwers may have difficulty returning to their sport at the same level of intensity, and should be addressed independently.
A method for directly measuring the position of the humeral head on the face of the glenoid in different positions of abduction of the arm was developed. We studied three subject groups: 12 patients with normal shoulders (group 1), 15 patients with stage II impingement syndrome (group 2), and 20 patients with rotator cuff tears or stage III impingement (group 3). The study consisted of a series of anteroposterior roentgenograms in the plane of the scapula with the arm in neutral rotation. Roentgenograms were obtained at 20 degrees intervals as the arm was elevated in the plane of the scapula from 0 degree to 120 degrees. Patients held a weight equal to 2 1/2% of body weight in the hand. The parameters measured were excursion of the humeral head on the glenoid face, expressed as the distance that the center of the head lies above or below the center of the glenoid, arm angle, scapulothoracic angle, and glenohumeral angle. For patients with normal shoulders (group 1), there was no significant change in position of the humeral head with arm elevation. In contrast, those with stage II impingement (group 2) had significant (p < 0.05) superior displacement of the center of the humeral head with arm elevation. Patients with rotator cuff tears (group 3) demonstrated a significant rise (p < 0.05) during the first 40 degrees of abduction. The average position of the humeral head in the two pathologic patient groups was superior (p < 0.05) to the average head position in the normal patient group. There was no significant difference in head position between patients with stage II impingement and patients with rotator cuff tear. The ratio of the glenohumeral angle to the scapulothoracic angle during abduction was calculated for our patient groups. In both patient groups, arm abduction had a larger scapulothoracic component than for normal shoulders. The superior migration of the humeral head is a probable result of cuff failure, either partial or complete.
The goals of this study were to define biplanar glenohumeral kinematics and glenohumeral-scapulothoracic motion relationships in normal patients with a two-plane radiograph series and then in patients with anterior shoulder instability or rotator cuff tear both before surgery and after surgical repair and postoperative rehabilitation. A two-plane radiographic series of x-ray films in the scapular and horizontal (axillary) planes was performed. With these films, measurements of the relationship between the centers of the humeral head and glenoid and measurements of the component contributions of glenohumeral and scapulothoracic motion to total arm abduction were made. Six normal adults underwent x-ray evaluation to establish normal control values. Kappa analysis was used to determine reliability of technique. Eighteen patients with confirmed anterior shoulder instability (group A) and 15 with confirmed rotator cuff tears (group B) were studied before surgery. Seven (39%) of 18 of the patients in group A and all 15 (100%) of the patients in group B demonstrated superior translation of the humeral head during scapular plane abduction. In the horizontal plane 14 (78%) of 18 patients in group A (instability) and none in group B (rotator cuff tear) demonstrated abnormal anterior translation of the humeral head on the glenoid. Both groups demonstrated altered glenohumeral-scapulothoracic motion relationships compared with the normal control group. Two years after surgery 12 patients from group A and 14 patients from group B were restudied. All of these patients had demonstrated abnormalities of humeral head translation before surgery. For group A 12 (100%) of 12 patients demonstrated normal glenohumeral kinematics in both planes after open anterior stabilization. For group B 12 (86%) of 14 patients demonstrated normal glenohumeral kinematics in both planes after open rotator cuff repair. In group A the altered glenohumeral-scapulothoracic motion relationships persisted, whereas in group B these relationships became normal.
UNLABELLED: This is a retrospective review of 40 patients who underwent arthroscopic labral debridement of the shoulder. All patients were active participants in sports involving use of the shoulder. All patients presented with shoulder pain. Only 40% were found to have distinct glenohumeral instability on examination. At surgery, all patients had labral injury. Ten patients had anterosuperior labral tears, 20 had anteroinferior labral tears or detachments, and 10 had posteroinferior labral tears or detachments. Outcome was assessed at a minimum of 2 years (average, 43 months) postoperatively. Overall, only 7% of the patients had significant symptomatic relief at followup. However, 72% noted relief of symptoms during the 1st year after surgery, but there was deterioration over time. CONCLUSION: Arthroscopic labral debridement is not an effective long-term solution for symptomatic relief in the overhead athlete.
The purpose of this study was to evaluate the sensitivity, specificity, negative and positive predictive values, and accuracy of the shoulder relocation test in 100 patients who underwent shoulder surgery. Based on operative data and examination under anesthesia, the diagnoses were grouped into six categories: anterior instability (without cuff disease), posterior instability, rotator cuff disease (without associated anterior instability), acromioclavicular disorder, osteoarthrosis, and instability of the biceps tendon. The test was performed on the day of surgery by placing the arm in a position of 90 degrees of humerothoracic abduction and 90 degrees of external rotation (90 degrees/90 degrees). Patient responses of pain and apprehension (considered separately) were assessed in this position both with and without application of an anterior force to the proximal humerus. The relocation test assessed diminution of pain and apprehension after application of a posteriorly directed force to the proximal humerus relative to the position of 90 degrees/90 degrees alone and to the position of an anterior force being applied to the proximal humerus. Overall, 63 patients reported pain with 90 degrees/90 degrees; 74 reported pain when an anterior force to the proximal humerus was applied: the anterior instability group alone had 46 and 63 reports of pain, respectively; the rotator cuff group alone had 82 and 88 reports of pain, respectively. The only positive responses for apprehension were in the anterior instability group, of which 63% had apprehension with 90 degrees/90 degrees alone and 74 had apprehension when an anterior humeral force was applied.(ABSTRACT TRUNCATED AT 250 WORDS)
The extent that the medial collateral ligament complex could be visualized by arthroscopy was determined in 10 fresh cadaveric elbows from 10 individuals. We carefully exposed the medial collateral ligament complex through a muscle-splitting incision before performing arthroscopy. The anterior and posterior bundles were identified and marked by placing 4.0 nylon sutures deep to the bundles to aid in arthroscopic visualization. A portion of the anterior bundle was visible in only one elbow and in that elbow only the most anterior 25% of the anterior bundle was seen. Attempts to visualize the anterior bundle through additional portals were unsuccessful. Varying the flexion angle of the cadaveric elbow from 0 degrees to 130 degrees also failed to improve visualization. Conversely, the entire posterior bundle, including humeral and ulnar insertion sites, could be seen in all 10 specimens using the posterior portals. We also noted that direct pressure was placed on the ulnar nerve in all specimens when the arthroscope or any arthroscopic instrument was advanced into the posteromedial gutter in contact with the posterior bundle because of its proximity immediately adjacent to the ulnar nerve. The inability to reliably see the anterior bundle and the humeral or ulnar insertion sites of this ligament may limit the value of the arthroscope when assessing medial collateral ligament injuries. Additionally, great care should be taken when using the arthroscope or other instruments in the posteromedial gutter because the ulnar nerve lies immediately adjacent to the thin posterior bundle and capsule.
Fifteen patients noted at surgery to have an isolated defect in the rotator interval and no other pathologic abnormality underwent closure of the defect as an isolated procedure for recurrent instability symptoms. Intraoperative assessment of each of these shoulders after the closure demonstrated adequate stability, and no other stabilization procedures were performed. The average age of the patients was 24 years, and 10 of the 15 patients were women. Examination under anesthesia revealed increased inferior translation in all patients, as illustrated by at least a 1+ sulcus sign. The rotator interval defect averaged 2.75 cm in width and 2.3 cm in height. The rotator interval defect edges were freshened and approximated (nine patients) or imbricated (six patients), depending on the anterior capsular laxity and the degree of glenohumeral joint translation possible. Followup averaged 3.3 years (range, 2.2 to 5.3), and all patients achieved either a good or excellent result using the American Shoulder and Elbow Surgeons evaluation scale and the Rowe rating scale. Although most patients with a defect in the rotator interval require a standard stabilization procedure as a supplement to closure of the defect, approximation or imbrication of the defect as an initial step at surgery may confer adequate stability in selected patients and obviate the need for formal capsular advancement.
Seven fresh-frozen cadaveric elbows were used to evaluate the extent to which the medial collateral ligament must be injured before arthroscopic evidence of valgus instability is seen, the amount of ulnohumeral joint opening that does occur after such an injury, and the elbow position that maximizes visualization of this opening. While visualizing the most medial aspect of the ulnohumeral joint arthroscopically through the anterolateral portal, we sequentially sectioned the medial collateral ligament complex until all of the medial ligamentous restraints were cut. A valgus load was applied after each incision, and the extent to which the ulnohumeral joint opened was measured. Ulnohumeral joint opening was not visualized in any specimen until complete sectioning of the anterior bundle was performed. After the anterior bundle was released, 1 or 2 mm of joint opening was present in all specimens. Complete release of the medial collateral ligament led to dramatic increases in medial joint opening in all seven specimens (4 to 10 mm). Varying the angle of elbow flexion from 15 degrees to 120 degrees revealed that visualization of the medial joint opening was best at 60 degrees to 75 degrees. Finally, forearm pronation increased ulnohumeral joint opening and supination decreased joint opening in all specimens. We found that the entire anterior bundle must be sectioned before measurable and reproducible medial joint opening can occur.
Thirty-seven of 41 consecutive patients with recurrent anterior instability of the shoulder were retrospectively observed for a mean of 5.6 years (range, 4 to 10) after an arthroscopic stabilization procedure had been performed. The operative technique involved the use of transglenoid sutures to repair the capsule and labrum. According to the criteria established by Rowe, 27 patients (74%) had good or excellent results, and 3 patients (7%) were graded as fair. Seven patients (19%) developed recurrent instability after the procedure and had failed results. Failure rates were equal in patients with a history of recurrent dislocation and those with recurrent subluxation. Absence of a Bankart lesion at operation was associated with postoperative instability (P = 0.03). The presence or size of humeral head defects did not influence the result. Eight of 12 athletes who engaged in sports requiring repetitive overhead shoulder motion returned to full activity, and none of the 12 developed instability after operation. Four of the 13 patients who participated in contact sports or recreational skiing developed postoperative instability (P = 0.21). All failures occurred within 2 years of the procedure.
The standard surgical approach for repair or reconstruction of the ulnar collateral ligament of the elbow involves lifting off of the tendon of the common flexor bundle at its origin on the medial epicondyle. However, a more limited muscle-splitting approach may be feasible. A muscle-splitting approach is less traumatic to the flexor-pronator muscle mass, and it could decrease operative time and lessen immediate morbidity after surgery. A proposed muscle-split through the common flexor bundle extends from the medial humeral epicondyle to a point distal to the tubercle of the ulna such that repair or reconstruction can be performed on the ulnar collateral ligament. To examine the feasibility of this approach, we performed a study combining anatomic dissections with clinical observations. We dissected 15 fresh-frozen adult cadaveric elbows to examine the neuroanatomy of the medial side of the elbow. All pertinent nerves were identified and mapped. From these data, we defined a "safe zone" for a muscle-splitting approach to the ulnar collateral ligament that allows adequate room for repair or reconstruction of the ligament without risking denervation of the surrounding musculature. The safe zone extends from the medial humeral epicondyle to approximately 1 cm distal to the insertion of the ulnar collateral ligament on the tubercle of the ulna. Twenty-two patients with ulnar collateral ligament tears underwent either a direct repair or a reconstruction of the ligament using the proposed muscle-splitting approach. With a minimum followup of 1 year, there was no clinical evidence of muscle denervation. From the combined anatomic study and clinical data, we believe that a less traumatic muscle-splitting approach to the ulnar collateral ligament affords a safe and simple surgical approach for repair or reconstruction of the ligament.
The study population consisted of 14 shoulders in 13 consecutive patients with surgically confirmed isolated subscapularis tendon tears. In all but three patients, the mechanism of injury was traumatic hyperextension or external rotation of the abducted arm. All patients reported pain and weakness in the affected shoulder. Physical findings revealed limited passive range of motion at maximal internal and external rotation due to pain, weakness of internal rotation of the shoulder, and tenderness in the region of the intertubercular groove. However, these findings did not conclusively point to the subscapularis tendon as the site of injury. Preoperative interpretation of magnetic resonance imaging studies was used to diagnose tears of the subscapularis tendon in 14 shoulders and biceps tendon subluxation or dislocation in 6 shoulders. On arthroscopic examination, one patient was found to have a partial-thickness tear that was treated with arthroscopic debridement. Six shoulders had full-thickness tears of the subscapularis tendon, and seven shoulders had full-thickness tears associated with concomitant biceps tendon pathologic conditions, including subluxation, dislocation, or rupture. The full-thickness subscapularis tendon tears were repaired via an open anterior approach to the shoulder through the deltopectoral groove. Associated biceps tendon injuries were treated with tenodesis of the tendon to the intertubercular groove. Our early followup results have shown that, with proper diagnoses and surgical treatments, patients have greatly decreased pain and marked improvement in shoulder function.
Forty-three athletes under age 40, more than half of which were collegiate or professional, with partial rotator cuff tears were treated arthroscopically and observed for a minimum of 24 months. By history and mechanism of injury, two main groups were identified. Group A had 14 patients with acute, traumatic injuries. All 14 had inflamed subacromial bursas, but increased glenohumeral translation and labral lesions were uncommon. Twelve patients (86%) had satisfactory postoperative results and nine (64%) returned to preinjury sports after arthroscopic subacromial decompression and tear debridement. Group B had 29 overhead athletes with insidious, atraumatic shoulder pain. They were not as successful with debridement (19 [66%] satisfactory and 13 [45%] return to preinjury sports). Within Group B, three subgroups were identified based on the examination under anesthesia and subacromial inflammation. Group B1 (8 patients) had normal-appearing subacromial spaces and often increased anterior glenohumeral translation with posterior labral tears. These patients did poorly after arthroscopic tear debridement (3 [38%] satisfactory and 2 [25%] return to sports). Group B2 (12 patients) had inflamed subacromial bursas and increased glenohumeral translation. This group had marginal results with debridement (7 [58%] satisfactory and 6 [50%] return to sports). Group B3 (9 patients) with subacromial inflammation, yet without increased glenohumeral translation, had excellent pain relief (100%) but less than half (4) returned to preinjury sports.
Previous studies report that noncontrast magnetic resonance imaging is limited in the evaluation of the superior glenoid labrum. From our magnetic resonance imaging database of 2552 patients, we prospectively identified 104 patients with superior labral lesions who subsequently went on to arthroscopic surgery. Magnetic resonance images were assessed to identify fraying, flap tears, bucket-handle tears, or displaced flap of fibrocartilage. The biceps tendon was also evaluated. Patients were categorized according to Snyder's classification, and the findings on the magnetic resonance images were correlated with surgical findings. One hundred of the 104 tears suspected on the images were confirmed at surgery. There were four false-positives and two false-negatives, the former reflecting one normal labrum, two meniscoid-type labra, and one sublabral foramen. With arthroscopic surgery as the standard, magnetic resonance imaging had a sensitivity of 98.0% (100 of 102), a specificity of 89.5% (34 of 38), and an accuracy of 95.7% (134 of 140) for detection of superior labral lesions. We concluded that high-resolution noncontrast magnetic resonance imaging can accurately diagnose superior labral lesions and aid in surgical management.
Baseball pitchers appear to be prone to aneurysms of the axillary artery and its branches. The cause is probably related to repetitive compression of or tension on the vessels at the level of the pectoralis minor muscle and the humeral head, which is exacerbated by the pitching motion. The incidence of aneurysms of the axillary artery and its branches among pitchers and other athletes is not known, nor is it clear whether pitchers who are at high risk of vascular injury can be identified before irreversible damage to the vessels has occurred. Perhaps patients who have documented compression or occlusion of the vessel with the arm in the abducted, externally rotated position are at higher risk. Screening pitchers to identify those with axillary artery compression, aneurysm, or thrombosis has also not been shown to be effective. Certainly, many pitchers will have some level of compression of the axillary artery with their arm in the pitching position but will never develop any clinical abnormality requiring treatment. Screening would therefore probably lead to a high false-positive rate. It is clear, however, that pitchers who complain of ischemia-type symptoms such as early fatigue or who have evidence of emboli require a complete evaluation to rule out any abnormality of the axillary artery or one of its branches. Orthopaedic surgeons who see pitchers and other athletes involved in repetitive overhead motions need to be aware of this disorder so that they order the appropriate tests and obtain a vascular consultation--and make a prompt diagnosis. Treatment will vary depending on the type of lesion and on which vessel or vessels are involved, and should be decided on by the team of surgeons treating the patient.