Instability of shoulder in throwing sports.
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Adolescent↗
Biomedical subjects
R F Warren
Publications and source records attributed to R F Warren.
Acute repairs of the anterior cruciate ligament--past and present.
This article begins with a discussion of the anatomy, mechanism of injury, diagnosis, and natural history of untreated anterior cruciate ligament tears. The patient selection criteria and the present technique for repair of the anterior cruciate ligament are then described.
Humans↗
The roentgenographic evaluation of anterior shoulder instability.
Retrospective evaluations of roentgenograms of 83 patients with unilateral shoulder instability were surveyed to evaluate the usefulness of various radiographic projections and to correlate the information with the osseous pathology associated with prior glenohumeral dislocation. The Hill-Sachs and the osseous Bankart defects were considered pathognomonic radiographic signs of glenohumeral joint instability. Based on history, physical examination, and examination under general anesthesia, patients were divided into three categories--(1) dislocation group, (2) subluxation group, and (3) combination group. Roentgen projections evaluated included the anteroposterior view with the humerus in internal and external rotation, axillary view, West Point view, Stryker notch, and Didiee view. The Hill-Sachs defect on the posterolateral aspect of the humeral head was best demonstrated on the combination of an internal rotation and a Stryker notch view. The osseous Bankart defect on the anteroinferior glenoid rim was best documented on the Didiee and West Point views. The external rotation and axillary view did not add significantly to the preoperative radiographic findings. In a patient with an unstable shoulder, a radiographic series that includes an internal rotation, a Stryker notch view, and either a West Point or a Didiee view would maximize the diagnostic yield per radiographic cost, time, and exposure.
Adolescent↗
Complete knee dislocation. A follow-up study of operative treatment.
Twenty knee dislocations in 19 patients (one bilateral) occurred over a period of 20 years. The age range was 21 to 65 years, with an average age of 40.8 years. There were two popliteal artery and eight peroneal nerve injuries in the group. All patients were managed by early closed reduction at the scene of the accident or at the admitting hospital. Treatment consisted of 13 acute arthrotomies with complete ligamentous repair, one partial ligament repair, two delayed repairs, and four cast applications. Both anterior and posterior cruciate ligaments were torn in each knee surgically examined. In contrast to cruciate injuries in nondislocated knees, avulsion of bone of the PCL was present in 14 of 16 and of the ACL in ten of 16. Complete follow-up study including examination and radiographic evaluation was obtained on 18 knees in 17 patients. Special investigations of 13 with acute complete ligament repair, followed from 12 months to 48 months (average of 24 months), showed loss of joint motion following this injury. Clinical instability was generally not a problem, but chronic pain and discomfort were present in 46%. The average knee diagnostic score was 43. Seventy-seven percent of the patients returned to vigorous sports activities. Early operative repair followed by cast bracing and manipulation at three months (if flexion was less than 90 degrees) is recommended in young, active patients.
Adult↗
Medial restraints to anterior-posterior motion of the knee.
We investigated the motion of cadaver knees before and after section of the medial structures and anterior cruciate ligament. The knees were tested using a 5-degrees-of-freedom in vitro knee-testing apparatus that measured anterior-posterior, medial-hateral, and axial displacement as well as internal-external and valgus-varus rotation. The fiexion angle could be varied but was fixed for each individual test. A 125-newton anterior-posterior force was applied perpendicular to the tibial shaft and the resulting motion of the knee was measured. In five knees the anterior cruciate ligament was cut first, followed by progressive cuts of the structures on the medial side (superficial medial collateral ligament, deep medial ligament, oblique fibers of the superficial medial ligament, and the posteromedial part of the capsule). Conversely, in five knees the medial structures were progressively cut first, followed by section of the anterior cruciate ligament. Tests were performed after each cut. With an intact anterior cruciate ligament, progressive cutting of the medial side had no effect on anterior and posterior displacements. When section of the medial structures followed cutting of the anterior cruciate ligament, anterior displacement exceeded that seen after isolated section of the anterior cruciate ligament. The anterior and posterior load-tests were repeated with the tibia fixed in 5 degrees of internal and 5 degrees of external rotation. Fixed external notation had no effect on anterior and posterior displacements. Fixed internal rotation significantly decreased anterior displacement only when both the anterior cruciate ligament and the medial structures were cut. The amounts of tibial rotation and tibial torque resulting from the applied anterior and posterior forces were low compared with our previous results, and we attributed this to decreased constraints on motion of the knee in the current testing apparatus. CLINICAL RELEVANCE: Athletic injuries of the knee frequently involve both the anterior cruciate ligament and the medial side of the knee. Clinical studies have demonstrated that combined injuries of the anterior cruciate and medial collateral ligaments often cannot be successfully managed conservatively. Our in vitro findings support the clinical data and suggest that injuries to the medial structures further compromise anterior stability when they accompany anterior cruciate injuries.
Adult↗
An anteromedial approach to the posterior cruciate ligament.
A straight anteromedial incision for the exposure of the medial, posteromedial, and posterior ligaments of the knee provides favorable exposure of the distal attachment site of the posterior cruciate ligament. This approach enables a medial parapatellar arthrotomy to be performed through the same incision. The key elements of the exposure are the reflection of the semimembranosus tendon and detachment of the posterior capsule from the medial meniscus.
Humans↗
The accuracy of double-contrast arthrographic evaluation of the anterior cruciate ligament. A retrospective review of one hundred and sixty-three knees with surgical confirmation.
In a retrospective review of 163 knees, the double-contrast arthrogram proved to be an accurate method of evaluating the anterior cruciate ligament. The status of the ligament was examined arthrographically with two stress lateral projections: a horizontal cross-table radiograph and a fluoroscopic spot radiograph. The condition of the ligament was interpreted as being normal, lax but intact, torn with intact synovial tissue, or torn or absent. The status of the ligament was subsequently determined at either arthrotomy or arthroscopy by inspection, palpation, and judgment of the degree of tension under stress. The arthrographic diagnosis was found to be 91.4 per cent accurate within the individual subclassifications and 95 per cent accurate in confirming the ligament to be either intact or abnormal. Injury to the anterior cruciate ligament frequently occurs in association with meniscal tears. In our series, 138 of the 163 knees had either a meniscal or a cruciate lesion, or both. Of these, forty-one (30 per cent) had a meniscal lesion, thirty-four (25 per cent) had a cruciate lesion, and sixty-three (45 per cent) had both. We have found the double-contrast arthrogram to be an accurate method of determining the condition of both the anterior cruciate ligament and the menisci in a single outpatient examination.
Adolescent↗
Plica synovialis infrapatellaris: arthrographic sign of anterior cruciate ligament disruption.
The plica synovialis infrapatellaris is occasionally identified arthrographically and can be confused with an intact anterior cruciate ligament. In our series, the plica synovialis infrapatellaris was never found in association with an intact anterior cruciate ligament; proper recognition of this structure is diagnostic of a torn anterior cruciate ligament. The plica synovialis infrapatellaris can be distinguished from an intact anterior cruciate ligament primarily by its anteroinferior insertion point which is on the infrapatellar fat pad or anterior edge of the tibial plateau. In comparison, the anterior cruciate ligament is just anterior to the tibial spines. A secondary method for differentiating a plica synovialis infrapatellaris from an intact anterior cruciate ligament, the "apical angle," is also described.
Adolescent↗
Subluxation of the shoulder in athletes.
Shoulder subluxation is an extremely common problem confronting the sports medicine physician and may present in a variety of ways, with the patient complaining of pain of a sense of instability. In throwing spots, tendinitis secondary to impingement is common, but it may also be secondary to instability as a result of traction or compression of the rotator cuff. In addition, subluxation may develop initially, then progress to dislocation, or the converse may occur. However, some patients may have subluxation over an extended period of time. The physician must consider the entity and take a careful history, followed by an examination that notes subtle losses of motion and strength and the presence of apprehension. The x-ray films may be helpful when the standard views are supplemented by the West Point and Stryker notch views. Examination under anesthesia and arthroscopy have played an increasingly significant role in the recognition and evaluation of these patients. At times, arthroscopy is helpful in the treatment of shoulder subluxation in patients who have partial labral detachment. This is mainly in throwers or tennis players in whom open surgery is likely to result in significant loss of athletic ability. Stretching and strengthening exercises are frequently helpful in managing subluxations and tendinitis associated with the microtrauma of repetitive use in contrast to traumatic subluxation. Operative procedures are indicated after the failure of conservative treatment. It is important to explore the joint to find loose bodies and to note any labral damage or detachment. Great care must be taken to avoid excessively tightening the capsule, which will limit athletic activity and may increase the instability in the opposite direction. Postoperatively, a well-directed exercise program to restore the patient's flexibility and strength is indicated prior to the resumption of any sporting activity.
Arthrography↗
The effect of medial meniscectomy on anterior-posterior motion of the knee.
We used an in vitro knee-testing apparatus to measure anterior-posterior displacement of the tibia on the femur and the accompanying tibial rotation in response to an applied anterior-posterior force. Testing was performed on nine intact knees, on five knees after medial meniscectomy, on three knees after isolated section of the anterior cruciate ligament, and on eight knees after both excision of the medial meniscus and section of the anterior cruciate ligament. The induced anterior-posterior displacement and the coupled rotation were unaffected by meniscectomy. Isolated section of the anterior cruciate ligament allowed a significant (p less than 0.05) increase in anterior displacement but had no effect on posterior displacement. The coupled internal rotation associated with anterior displacement was lost after section of the anterior cruciate ligament. Excision of the medial meniscus and section of the anterior cruciate ligament allowed significantly (p less than 0.05) greater increases in anterior displacement than those already increased by isolated section of the anterior cruciate ligament.
Aged↗
An in vitro biomechanical evaluation of anterior-posterior motion of the knee. Tibial displacement, rotation, and torque.
We tested the anterior-posterior motion of nine normal cadaver knees in zero to 90 degrees of flexion using a specially designed apparatus. This apparatus applied a dynamic anterior-posterior force to each knee and measured the resulting tibial displacement, rotation, and torque. In the intact knee, an anterior force produced an internal tibial torque and internal tibial rotation, while a posterior force produced an external torque and external rotation. Anterior-posterior displacement increased by 30 per cent when the tibia was allowed to rotate freely about its neutral rotation position. Isolated section of the anterior cruciate ligament produced more than double the amount of anterior displacement without affecting posterior displacement. Isolated section of the posterior cruciate ligament produced almost triple the amount of posterior displacement without affecting anterior displacement. After cutting either the anterior or the posterior cruciate ligament, the resulting internal or external secondary tibial rotation disappeared. It appears, therefore, that the anterior and posterior cruciate ligaments are the primary restraints to motion in the anterior and posterior directions as well as the causes of internal and external tibial rotation during anterior and posterior motion.
Aged↗
Surgical treatment of lesions of the long head of the biceps.
A follow-up study was carried out on 20 patients with a Hitchcock type of biceps tenodesis performed during the past seven years at the Hospital for Special Surgery. Thirteen cases were diagnosed as biceps tendinitis and seven as biceps instability. At follow-up, there was a 30% failure rate; the failures were related to misdiagnosing biceps instability, not identifying an impingement syndrome, or glenohumeral instability. Those patients who were relieved of symptoms had in addition to biceps tenodesis, an excision of a portion of the coracoacromial ligament. In four of the six failures, the coracoacromial ligament was not released. Two patients had a fixed dislocation of the biceps tendon noted preoperatively by arthrography and confirmed at surgery, and were successfully treated by biceps tenodesis. Two other patients who had unsuccessful biceps tenodesis and coracoacromial ligament excision were subsequently shown to have humeral head impingement with the coracoid process. Coracoid osteotomy relieved their pain. The role of the biceps tendon in the production of shoulder pain is difficult to assess and is easily overestimated, The biceps tendon inflammation may be a secondary manifestation of an impingement syndrome and unless treated as such, surgery will not be successful. Conversely, biceps lesions secondary to disorders of the bicipital groove can be treated by tenodesis. Instability of the biceps tendon can be difficult to evaluate preoperatively. Arthrography was noted to be diagnostic in dislocation of the biceps tendon.
Adolescent↗
The structure of the posterolateral aspect of the knee.
The lateral structures of the knee can be divided into three distinct layers. The deepest layer, the lateral part of the capsule, divides into two laminae just posterior to the overlying iliotibial tract. These laminae encompass three ligaments: the lateral collateral, the fabellofibular, and the arcuate ligaments. Three major anatomical variations are seen: reinforcement of the capsule by the arcuate ligament alone (13 per cent), by the fabellofibular ligament alone (20 per cent), and by both ligaments (67 per cent). One can predict which variation will be seen in a given patient from the information provided by a radiograph and by physical examination.
Humans↗
Posterior heel pain associated with a calcaneal step and Achilles tendon calcification.
Factors are examined which may be associated with chronic posterior heel pain of nonrheumatologic and nonmetabolic etiology. The charts of patients in whom Haglund's disease retrocalcaneal bursitis, or "pump bumps" was diagnosed during the period from 1963-1978 at The Hospital for Special Surgery, were reviewed. Nineteen patients met the criteria of symptomatic patients. The radiographs in 12 of these patients were available for review. These cases and 104 control cases were evaluated for the presence of calcaneal spurs, Achilles tendon calcifications and a posterior calcaneal step. In addition, Fowler-Philip measurements were obtained from the radiographs and compared with Fowler and Philip's results. Although the Fowler-Philip angles of the two groups were not significantly different (p greater than 0.05), the symptomatic heels had a significantly longer horizontal calcaneal length (p less than 0.05). The incidences of Achilles tendon calcification (p = 0.004) and of a posterior calcaneal step (p less than 0.001) were higher in patients who had chronic posterior heel pain as compared to a control population. An increased horizontal length of the calcaneus and the presence of a posterior calcaneal step appeared to cause chronic posterior heel pain and degenerative lesions of the Achilles tendon. Although a posterosuperior calcaneal prominence is theoretically important, it was not in this series. A posterior calcaneal step may alter the tension within the tendon, resulting in microscopic tendon injury, decreased vascularity and loss of strength, with subsequent calcification or rupture.
Achilles Tendon↗
Stress fractures of the pubic ramus. A report of twelve cases.
Twelve stress fractures of the pubic arch were seen in eleven patients who were joggers, long-distance runners, or marathoners. In two of the fractures there were complications of healing; that is, delayed union or refracture. With two exceptions, the lesions occurred in women between the ages of nineteen and forty-eight. In all of the patients the fracture was in the inferior pubic ramus near the symphysis pubis, and caused pain in the groin, buttock, or thigh. All fractures were non-displaced and easy to overlook on the initial radiographic examination; when a fracture of the pubic arch was clinically suspected but the radiographs were normal, a radionuclide bone scan was diagnostic. After identification of the fracture, running had to be curtailed until the symptoms disappeared in order for healing to occur.
Adult↗
Persistent vertical septum in the human knee joint.
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Adolescent↗
Recurrent dislocation of the shoulder after age fifty.
Recurrent dislocation of the shoulder is infrequent in patients over the age of 50. In a small group of 6 patients with an average age of 64 years and multiple recurrences, 4 subsequently were treated by anterior capsulorraphy (Bankart). There was an unusual degree of loose jointedness in all 6 cases. When compared with a group of patients under the age of 30 with recurrent dislocation of the shoulder, the older group was functionally rated 19.4 out of a possible score of 25 points, compared with a rating of 10.8 in the younger group. In the older population, recurrent dislocation may become a problem if the patient is loose-jointed. Immobilization for 3 to 4 weeks may not be helpful in this group of patients. Anterior capsulorraphy is as successful as in younger patients and is not followed by unusual joint stiffness.
Age Factors↗
Double-contrast arthrography of the elbow.
Double-contrast arthrography using gravity provides more detail than single-contrast techniques. With gravity, air rises to the uppermost portion of the joint and the positive contrast material settles. The cartilagenous articular surfaces and the synovial lining of the elbow are coated with contrast material and highlighted by the intra-articular air. Cartilagenous intra-articular bodies can be identified and located and the size of cartilagenous encapsulated osseous bodies can be confirmed. This method is faster to perform and easier to interpret than single-contrast studies, exposes the patient less than a tomographic examination, and is helpful before surgical exploration.
Adolescent↗