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[Occupational arm ailments in musicians].

We began our specific interest in this subject in 1975 and to date have seen and treated over 600 musicians with functional problems of the upper limb. These are common problems affecting over one third of instrumental musicians. Every instrument may have its own specific repercussions. However certain factors may influence their onset: intensive practice; a technique requiring non-physiological positioning; a change in technique, instrument or habits; pre-existing trauma; psychological predisposition; inappropriate physique. The presentations are varied and the limits imprecise. Muscles, tendons, joints and nerves may be involved. The commonest, and easiest to cure are due to pain resulting from overuse syndromes cover a multitude of sins resulting from marked physical effort in excess of the normal physiological capacity of the body. Joint instability and degenerative disease pose their own specific problems. Peripheral nerve lesions can be related to overuse syndromes or to the adoption of non-physiological or harmful positions. The most difficult problems to deal with are those related to a loss of motor control when performing the same repetitive movement--functional dystonia. Their origin remains obscure with the major discussion revolving around either a neurological or organic aetiology. Our intensive experience of instrumentalists with these problems secondary to bad positioning or posture, has led us to propose a therapeutic regime based on structured re-education and relaxation. The great majority of sufferers overuse syndromes or functional dystonias have been able to resume their professional activities. It is clear that functional dystonias are curable if treatment is instituted early and that the lesions are not too long standing.

Arm Injuries↗

Surgical treatment of the duplicated thumb.

Fifteen patients with 18 duplicated thumbs were treated surgically at The Shriners Hospital for Crippled Children, Springfield Unit, between 1925 and 1990. We compared the outcome of patients treated by ablation of the extra thumb with that of patients treated by ablation and radial collateral ligament reconstruction. Three patients with four duplicated thumbs, all from the ablation-only group, required additional surgical treatment for the following reasons: joint instability, contracture, angulation of the digit, and bony prominence. No patient from the ablation-plus-ligament-reconstruction group has required further operative treatment.

Child↗

Complications associated with harvesting autogenous iliac bone graft.

The harvesting of an autogenous iliac bone graft is a frequently performed orthopedic procedure. Although often regarded as the simple or routine part of bone graft requiring surgery, complications are not necessarily uncommon. Documented donor-site complications include nerve, arterial, or urethral injury; chronic donor-site pain; cosmetic deformity; herniation of abdominal contents; sacroiliac joint instability; pelvic fractures; gait disturbances; hematoma; infection; peritoneal perforation; and hip subluxation. Most of these complications are avoidable when the surgeon is aware of their possibility and is familiar with the involved anatomy and preferred surgical approaches.

Aged↗

MR arthrography: is it worthwhile?

Magnetic resonance (MR) arthrography is possible in any joint in which standard arthrography is performed. The diagnostic potential of this technique is optimized in the assessment of complex anatomical structures and intra-articular abnormalities that are difficult to visualize on conventional MR images. This paper presents the most common applications of MR arthrography in the shoulder, hip, knee, ankle, elbow and wrist, and explores the clinical indications in which MR arthrography adds the greatest benefit compared to standard arthrography and conventional MR imaging. Arthrographic MR images are most valuable in the evaluation of glenoid and acetabular labra, tendons of the rotator cuff, post-operative menisci, osteochondral fractures and loose bodies.

Humans↗

MR imaging of the elbow. An update.

MR imaging provides clinically useful information in assessing the elbow joint. Superior depiction of muscles, ligaments, and tendons as well as the ability to visualize nerves, bone marrow, and hyaline cartilage directly are advantages of MR imaging relative to conventional imaging techniques. These features of MR imaging may help to establish the cause of elbow pain by accurately depicting the presence and extent of bone and soft-tissue pathology. Ongoing improvements in surface coil design and newer pulse sequences have resulted in higher quality MR images of the elbow that can be obtained more rapidly. Recent clinical experience has shown the utility of MR imaging in detecting and characterizing disorders of the elbow in a noninvasive fashion.

Collateral Ligaments↗

Mennen plate in hip and shoulder joint replacement.

Sixteen patients complicated by femoral fracture and aseptic loosening with severe bone loss and two patients complicated by humeral fracture after hip and shoulder joint replacement, respectively, were collected from the Carmel and Ichilov teaching hospitals. All patients underwent internal fixation with the Mennen plate or in conjunction with revision joint replacement, either for internal fixation or for bone graft support. The results were satisfactory in fifteen patients with respect to functional activity, pain, and the radiographic evaluation. In three patients who underwent their fourth revision, the results were unsatisfactory but were better than their preoperative status. Our conclusion is that Mennen plate fixation provides a sufficient and easy internal fixation technique for a fracture around or below the un-dislodged stem of hip and shoulder in joint replacement. In an unstable femoral fracture or in a case of aseptic loosenings with marked bone loss, we recommend Mennen plate fixation in conjunction with long stem revision total hip replacement and bone graft.

Aged↗

The cruciate ligaments of the canine stifle: an anatomical and functional analysis.

Fifty canine stifles were used to study the anatomy and function of the cruciate ligaments. The morphology of the ligaments and the shape of their bony attachments were determined by dissection. The relative tension of the ligaments in flexion and extension was determined by identifying the points of attachment of ligament fibers with small pins and making multiple radiographs as the stifle was taken through a range of motion. The distance between these points was then measured and the linear changes in the ligaments were defined. Measurements of rotation, craniocaudal displacement, extension, and flexion were made before and after cutting of one or both ligaments. It was found that both cruciate ligaments were composed of 2 component parts and that the geometry of their femoral attachments was responsible for a reciprocal loosening and tightening of these components through a range of motion. It was also found that transection of one or both cruciate ligaments resulted in marked joint instability.

Animals↗

[Giants schwannoma of the sacrum. Apropos of 3 cases and review of the literature].

Giant sacral schwannoma is a very rare tumor (25 cases reported). The authors report 3 cases of giant sacral schwannoma treated by curettage through posterior approach and discuss symptoms and treatment. These tumors were characterized by their minimal symptoms compared to radiographic findings. Magnetic resonance imaging must be performed in order to detect extraosseous tissue component and intradural invasion. A biopsy was performed to confirm the diagnosis before definitive treatment. Wide resection was proposed by many authors because of the high recurrence rate. We believe that a wide resection is too sever as it causes neurologic sacrifices. A curettage through posterior approach preserves nerve function, and if a local recurrence occurs it remains possible to perform a wide resection. When sacroiliac joint instability is detected, a lumboiliac arthrodesis is indicated. Osteosynthesis could be performed with spine device (using pedicular and iliac screws).

Adult↗

Lateral instability of the ankle joint.

Acute lateral ankle ligament ruptures are successfully treated nonoperatively with physiotherapy, peroneal strengthening, and coordination training. About 10-20% of patients may develop functional instability despite adequate nonoperative treatment. Chronic functional instability is not always a severe disability, but reconstruction of the lateral ankle ligaments may be necessary for patients with high demands on ankle stability. More than 50 different surgical procedures for the treatment of chronic lateral ankle joint instability have been described. Most of these are tenodeses where one of the peroneus tendons is used, such as Evans, Watson-Jones, and Chrisman-Snook reconstructions. Good short-term results have been reported, but the long-term results after the Evans and Watson-Jones reconstructions are worse than anticipated. Anatomic ligament reconstruction with shortening, reinsertion, and imbrication of the elongated ligaments, a simple procedure with good long-term results, might be a better alternative than other more complex ligament reconstructions.

Ankle Injuries↗

Traumatic instability of the proximal tibiofibular joint.

Proximal tibiofibular instability, seems to be an infrequently diagnosed abnormality, which occurs in isolation or in combination with fractures of the leg and ankle. Four types of instability are distinguished: subluxation, anterolateral dislocation, posteromedial dislocation and superior dislocation. The method of treatment depends on the type of dislocation and on the presence or absence of dysfunction of the peroneal nerve. The methods of treatment are described. Ten patients treated for this instability are presented. The use of radiographs to define the lesion is discussed. Radiographs, taken at follow-up, showed degenerative changes in the proximal tibiofibular joint in 8 of the 10 patients.

Adolescent↗

Simultaneous dislocations of the radiocapitellar and distal radioulnar joints.

Posttraumatic instability of the distal radioulnar joint (DRUJ), occurring in isolation or in association with fractures of the radius, is well-documented. Few reports have identified simultaneous ipsilateral DRUJ instability and elbow dislocation. The authors of the present study describe a case of persistent radiocapitellar subluxation after closed reduction of an elbow dislocation, secondary to irreducible volar subluxation of the DRUJ.

Accidental Falls↗

Arthrography of the ankle joint in chronic instability.

Papers on arthrography of injuries of the lateral ligaments of the ankle relate mainly to recent distortion of the joint. Arthrography performed at a later stage after injury generally is considered useless. In fact, changes in chronic instability are observed; they are subtle and consist either of small recesses adjacent to the lateral malleolus or communication of the joint with the peroneal tendon sheaths. Arthrography was assessed in 61 cases of recurrent lateral sprains of the ankle more than 2 weeks after acute injury; 38 were considered as positive. Twenty-five patients had operative evaluation, with four false negative and one false positive results. Small recesses adjacent to the lateral malleolus or opacification of the peroneal tendon sheaths are sequelae of an acute sprain with tear of the anterior talofibular and/or the calcaneofibular ligaments. Although false negative results occur, arthrography is useful in the preoperative assessment of chronic ankle instability.

Adolescent↗

A soft tissue attempt to stabilize the multiply operated glenohumeral joint with multidirectional instability.

Treating patients with multidirectional instability who have had multiple failed stabilization procedures is a challenging problem. These patients have disability from instability and pain. Final treatment may be glenohumeral narthrodesis. We report on the results of a soft tissue operation for treatment of multidirectional instability in multiply operated shoulders. Since 1994, 28 patients have had what we term the kitchen sink operation for treatment of refractory multidirectional instability. After exclusion of patients with collagen abnormality, 10 patients who had at least three previous stabilizations were identified with recalcitrant multidirectional instability. The kitchen sink operation encompasses a humeral-based inferior capsular shift, Nicola biceps tenodesis, and coracohumeral ligament and rotator interval augmentation and/or reconstruction. All patients were immobilized for 8 weeks postoperatively. Minimum clinical and radiographic followup was 2 years (range, 2-6 years). Preoperatively, all patients had incapacitating pain and instability. Postoperatively, five patients (50%) had significant improvement of pain, and nine patients (90%) had successful reduction of instability. Four of the five patients with persistent disabling pain needed glenohumeral fusions. The kitchen sink operation is a final attempt to stabilize the shoulder with multidirectional instability. This procedure reduces instability (especially inferior) associated with multidirectional instability. However, pain remains unremitting in 50% of patients, therefore a glenohumeral arthrodesis may be needed as a last option.

Adult↗

Radiologic technique for measuring instability in the knee joint.

The measurement of anteroposterior instability as well as lateral and medical instability in the knee joint based upon radiologic films exposed while forces are being exerted on the patient in a specially constructed stress apparatus is described. Measurements on the films require detailed knowledge of the landmarks of the joint, alignment of baselines to special points, especially on the lateral projection, where anterior and posterior displacement should be measured for each tibial condyle to calculate the mean.

Female↗

[Rotatory instability of the knee joint in cases of previously treated "Unhappy Triad" (author's transl)].

The combined injury of the ligaments and capsular structures of the knee joint always causes rotatory instability as the sum of all or some a.m. injuries (Slocum; Nicholas). This has to be taken into account in the operative treatment. We have followed 14 patients with old "unhappy triad" injuries who had been operated upon with the question in mind whether the usual procedures with reefing of the ligaments or plastic replacements including meniscectomies, but without paying attention to the lax posterior capsule could correct the typical anteromedial rotatory instability. The results showed that this was true only in about half the cases. The remaining patients continued to complain about instability in the operated knee joint. Objectively, the pre-operatively positive rotatory drawer sign remained unchanged. Therefore we conclude that the anteromedial rotatory instability of the knee joint can be improved by the procedure devised by Slocum and Nicholas.

Adult↗

[Instability of the shoulder joint in the athlete].

In all shoulder instabilities it is very important to classify the type of instability precisely in order to choose the right form of therapy and predict the results. The acronyms TUBS, which means traumatic instability, unidirectional, Bankart lesion, and good response to surgery, and AMBRI, which means atraumatic aetiology, multidirectional, and good for rehabilitation, represent the complete range of possible instabilities. We discuss the subtypes in the differentiation of various instabilities and the different causes and pathologies for instability, the clinical and radiological tests possible, and the different surgical treatment options, as well as the results in the literature. A modification of the Bankart procedure and the arthroscopic Caspari capsulorrhaphy procedure for traumatic instabilities are described. The capsular T-shift by Neer and Foster is explained as a surgical treatment for multidirectional instability.

Arthroscopes↗