Biomedical subjects
Publications and source records attributed to H S Tullos.
Cadaveric dissections have demonstrated the precarious nature of the axillary nerve with relationship to three common sports medicine shoulder procedures: the anteroinferior acromioplasty and rotator cuff repair incision, the inferior capsular shift procedure, and the posterior portal for shoulder arthroscopy.
Anterior acromioplasty as described by Neer has been an effective procedure for shoulder impingement syndrome. Recent presentations by Ellman suggest that an effective acromioplasty may be performed arthroscopically. These clinical reports have not been supported by any laboratory experience. The purpose of our study was to examine the feasibility and attempt to quantitate the results of arthroscopic subacromial decompressions. Six acromioplasties were performed according to the recommended technique of Dr. Neer to create a standard for comparison. Fourteen fresh postmortem specimens were studied. In seven shoulders a standard acromioplasty was performed with an osteotome. In seven shoulders an acromioplasty was performed using standard arthroscopic approaches and motorized instruments. In five shoulders an isolated division of the coracoacromial ligament was performed arthroscopically. The coracoacromial ligament was completely divided in all five cases. In the osteotome group adequate bone was resected in 75% (21/28) measured locations. In the arthroscopic group adequate bone was removed at 86% (24/28) location. This difference is not statistically significant. In the cadaver, anterior acromioplasty was performed effectively and predictably with arthroscopic instruments. This compared favorably to a conventional osteotome acromioplasty. It was concluded that coracoacromial ligament division can be accomplished.
Using cadaveric specimens, we studied the effect of ACL deficiency upon anterior tibial translation during extension of the knee joint. Five knees were loaded via the quadriceps mechanism until flexion angles of 10 degrees, 25 degrees, 40 degrees, and 60 degrees were attained. At each angle, the anterior-posterior position of the tibia was documented with biplane radiography, both before and after division of the ACL. In every specimen, anterior tibial translation increased with loss of the ACL and was greatest at 25 degrees of flexion, where an average displacement of 3.3 mm was observed. Subluxation was not significant at flexion angles exceeding 60 degrees, regardless of ACL deficiency. We also examined the effect of an external restraining force on tibial subluxation in the ACL deficient knee. Posteriorly directed forces of 0 N, 45 N (10 pounds), 90 N (20 pounds), 135 N (30 pounds), and 225 N (50 pounds) were applied to the tibia at the level of the tibial tubercle. Anterior subluxation was eliminated through application of forces ranging from a maximum of 106 N (23.6 pounds) at 10 degrees to only 13 N (2.9 pounds) at 60 degrees.
Distal clavicle resection has been an effective procedure for treatment of acromioclavicular arthritis. The conventional open surgical technique involves deltoid detachment and reattachment, which may cause postoperative weakness and requires protection during the postoperative period to allow for healing. Arthroscopic acromioclavicular joint resection has the theoretical advantages of no deltoid disruption and a shorter rehabilitation period. The purpose of this study was to compare open versus arthroscopic acromioclavicular joint resection in a laboratory setting. The goals of acromioclavicular joint resection in this study were to remove 5 mm of the medial acromion and 10 mm of the distal clavicle. Acromioclavicular joint resections were performed on 10 cadaver shoulders (5 open resections and 5 arthroscopic resections). Open resection was successful at 10 of 15 distal clavicle locations and 14 of 15 medial acromial locations. Arthroscopic resection was successful at 14 of 15 distal clavicle locations and 10 of 15 medial acromial locations. The combined bone resection averaged 14.8 mm (+/- 1.99 mm) for the open technique and 14.8 mm (+/- 2.58 mm) for the arthroscopic technique. The combined bone resection was 1.5 cm or more in all of the measured locations for the open technique and in 14 of 15 measure locations for the arthroscopic technique. There was no statistically significant difference between the two groups. In the laboratory setting, acromioclavicular joint resection was performed effectively and predictably with arthroscopic instruments. Arthroscopic bone resection was comparable to open bone resection.
In 20 shoulders (19 patients) with a Bankart lesion, the isolated coracoid process was transferred as a bone graft to the anterior rim of the glenoid. The graft was positioned directly at the site of the Bankart lesion without displacing the insertion of the conjoined tendon or subscapularis. The average age of the patients was 22.5 years (range, 15 to 42). Follow-up examination at a minimum of 3 years (average, 55 months) showed 17 of 20 shoulders (85%) presented with good or excellent results. One recurrent dislocation was noted. There were no complications related to screw fixation of the coracoid process. External rotation loss of the operated arm in 90 degrees of abduction averaged only 5 degrees. Ten of 12 patients (83%) with an operation on the dominant shoulder returned to throwing sports and overhead motion activities. However, a 15% fair or poor rate suggests that this procedure may control dislocation, but that subluxation is not as well controlled.
The Blair fusion is the accepted method to achieve an ankle arthrodesis in the presence of avascular necrosis or absence of the body of the talus. This procedure has not however, been reliable. A pseudarthrosis rate of 28% and fibrous ankylosis of the foot secondary to prolonged immobilization compromise the end result. A tibiotalar compression arthrodesis has been developed using an intermediate hip compression screw and a modified Stone staple. Five patients with avascular necrosis of the talus underwent a modified Blair fusion. Protected weightbearing was started at 6 weeks and healing occurred within 3 months. Although the number of cases is small, this study indicates that the addition of compression fixation to the Blair arthrodesis will significantly decrease the pseudarthrosis rate and perhaps the healing time.
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Fifty-four cases of nonpathologic subtrochanteric fractures of the femur were treated by fixation with nail-plate devices. Of the 48 final cases, 42 patients (88%) united successfully after a single operative procedure. Six patients (12.5%) developed a non-union and required further surgery, an experience similar to that of other authors. Ten per cent appears to be the expected non-union rate with nail-plate devices. At this time the Jewett nail and the compression screw should be regarded as part of the the orthopedist's armamentarium in the treatment of comminuted subtrochanteric fractures of the femur.
The anterior oblique component of the medial collateral ligament of the elbow is the mainstay of joint stability. Fractures of the medial epicondyle must be anatomically reduced, open if necessary. A fibrous union of a minimally displaced fractured medial epicondyle may result in lengthening and functional compromise of the medial collateral ligament. Chronic elbow instability is an unusual lesion. Repair of chronic elbow instability is best performed by restitution of medial collateral ligament function.