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MR imaging of the shoulder without contrast is frequently used for evaluation of glenohumeral instability in spite of the popularity of MR arthrography. With proper imaging technique, familiarity with normal anatomy and variants as well as knowledge of the expected pathologic findings high diagnostic accuracy may be achieved.
To investigate the contribution of bony stability to the pathogenesis of the loose shoulder, geometric parameters of the acromion by use of cineradiography were evaluated in patients with a loose shoulder and compared with those in the normal shoulder. One hundred twenty healthy individuals and eighty-two patients were enrolled. To evaluate the size of the acromion and the coverage of the humeral head by the acromion, the anterior width of the acromion and three angle parameters were measured. The findings demonstrated that the loose shoulder had a relatively smaller and more upwardly inclined acromion that was against the glenoid and provided less coverage of the humeral head. These characteristics of the acromion may contribute to the hypermobility and functional instability of the shoulder joint observed in patients with a loose shoulder. Therefore, a radiographic evaluation of the geometry of the acromion is important to determine the pathogenesis of the loose shoulder.
The results of treatment by alloplastic ligament replacement are generally comparable to those achieved with autologous pedunculated or free tissue transplants with regard to band stability as well as total function. We consider the indication for this not yet universally recognised surgical technique with alloplastic material to lie exclusively in patients with multiple previous knee operations and for whom autologous tissue was not present in adequate quality intraoperatively. Here the usage of the polyester band was a last resort. The long term preservation of function and stability are ultimately the most important factors, but we cannot yet convincingly assess these after only one year's experience of this method. It is possible that the already known problems with only plastic possible corrections of chronic capsule-ligament instability of the knee joint can be reduced by the usage of polyester band.
The diagnostic steps and the indications for the treatment of chronic instability of the knee joint due to rupture (lesion) of the anterior cruciate ligament are discussed. After briefly mentioning the surgical technique we report on 250 dynamic surgical replacements of the anterior cruciate ligament by the proximally based gracile (semitendinous) tendon. For the operations performed between 1976 and 1983 a technique similar to Lindemann's was used. We would like to stress the importance of the reconstruction of injured synergistic stabilizators. The results of a control 1 to 8 years (mean 38 months) after the operation were very good in 21.2%, good in 66.8%, moderate in 9.2%, unsatisfactory in 1.6% and poor in 1.2% of the cases, although strict standards had been applied. We therefore recommend this technique for the treatment of lesions of the anterior cruciate ligament. Thorough after-treatment is of utmost importance for its outcome.
In cases of lateral ankle injury, although acute ligament ruptures are best treated non-operatively with physiotherapy (range-of-motion and co-ordination training, and peroneal muscle strengthening exercises), about 10-20 per cent of patients nonetheless develop chronic functional instability: While this is not severely disabling, ligament reconstruction may be necessary in specific cases, e g for those with high demands of ankle stability. Of the more than 50 surgical approaches published, several have become classic reconstructive procedures widely used--e g, those of Evans and Watson-Jones (with disappointing long-term results), and that of Chrisman-Snook (with satisfactory long-term outcome). However, anatomical ligament reconstruction (with shortening, re-insertion and imbrication of the healed but elongated ligament) is a simple procedure with good short- and long-term results, which may often be a better alternative than other more complex reconstructive procedures.
To correct chronic instability of the trapeziometacarpal joint, the authors reconstructs the posteromedial ligamentous complex using flaps of extensor retinaculum. Two small dorsal incisions allow harvesting free segments of extensor retinaculum detached from the proximal portion of extensor retinaculum to repair dorsal injuries when these prove to be superficial. When necessary, a clip passed via a small palmar cunter incision allows a complementary palmar reconstruction. For repair of anterior ligaments, the palmar incision can be extended and a pedicled flap derived from the retinaculum is used. There is a detailed description of technique and results.
Basing on a review of available literature the author presents 9 provocative tests used in clinical examination of carpal instabilities, their methodology and principles of clinical interpretation. Tests used to diagnose instabilities of the following joints are discussed: distal radio-ulnar, triquetro-hamate and luno-capitate.
A retrospective review of 30 patients on whom a double-contrast computed arthrotomogram of the shoulder was performed was evaluated to correlate radiographic findings with subsequent arthroscopic and surgical findings. Analysis of the data demonstrated a wide variation in abnormal computed tomography (CT) labral configurations, and experience was necessary to interpret the studies adequately. The lesions ranged from complete detachment to complete absence. The study was reliable in identifying large labral lesions suitable for arthroscopic stapling with large detachments anteriorly and anterior inferiorly. Isolated low anterior labral detachments associated clinically with instability under anesthesia were missed. The amount of tissue available for arthroscopic stapling correlated well with CT findings, making it a useful screening test to help select candidates for arthroscopic stapling. One false-positive study and two false-negative studies were noted, for an error rate of 10%. We recommend continued use of the CT arthrotomogram of the shoulder as a screening test for shoulder derangement and as a predictive adjunct for surgical planning. Modifications in our technique include tangential low anterior imaging to detect low anterior short labral detachments.
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Forty-two unstable ankle joints were treated surgically by Evans' operation. The clinical postoperative results were correlated with the objective radiological stress examinations. The mean age of the patients was 29 years (15-60 years). The clinical and radiological follow-up examinations were performed 6 months after the operation. In the stress X-ray examinations a modified stress frame was used. Clinical instability was noted in four patients. In the radiological examination one patient had a pathological finding in the talar tilt test and 18 patients in the anterior drawer sign test. The radiological instability correlated poorly with the subjective end results. Six patients were estimated to have a poor result of the operation. Five of these patients had a positive anterior drawer sign in the stress X-ray examination and one had degenerative changes in the ankle. Although Evans' repair is a simple and reliable method of reconstructing ruptures of the lateral ligaments of the ankle joint, it is associated with a relatively high frequency of positive anterior subluxation on radiological stress examination. This finding can be explained by the anatomical and geometrical factors on the lateral side of the ankle joint.
Commercially available fixation devices used for reattachment of capsuloligamentous tissue to the glenoid rim were tested until they failed in 42 human cadaveric shoulders, and compared to the tension strength of the standard Bankart procedure and that of the intact anterior capsule. The bone quality in the glenoid was measured by quantitative computed tomography, which allowed selective quantification of cortical and cancellous quantification of cortical and cancellous bone. The mean load at failure perpendicular to the bone surface varied from 90 to 115 N and was lower than in the standard Bankart procedure (127 N). All suture anchors demonstrated similar holding strength with the exception of an absorbable wedge (P < 0.05). Due to reduced mineral content in the inferior part of the glenoid, the fixation strength of all suture anchors was significantly decreased. In more than 20% a tension load of 100 N caused the suture anchor to pull out, but in general the fixation strength was limited by the suture attachment and the quality of the soft tissues. These data together with the first clinical results of 49 cases of anterior instability operated on between 1988 and 1992 allow the conclusion to be made that this modification will provide sufficient stability for early mobilization after surgical repair.
The authors present a rare case of transitory osteonecrosis of the humeral head with anterior instability of the glenohumeral joint, which occurred in a young male aged 19 years, three months after fracturing his clavicle in a fall. Core decompression of the humeral epiphysis and anterior capsulomioplasty according to Symeonides was performed. Five months after surgery the patient was clinically cured. After having excluded the possibility of metabolic imbalance in the patient, we presumed a direct relationship between the trauma and degenerative pathology affecting the humeral epiphysis.
Measurements of movement sense determined by threshold levels for the perception of motion of the shoulder were performed in 10 patients with unilateral posttraumatic shoulder instabilities, in 30 patients who underwent arthroscopic labrum repair for recurrent anterior shoulder instability, and in 15 age-related controls. In patients with anterior shoulder instabilities threshold levels for the perception of motion were higher. In addition, movement sense measurements revealed a marked, but time dependent improve of proprioceptive abilities in patients who underwent arthroscopic labrum repair. While in the shoulders of patients with an postoperative period shorter than 18 months elevated threshold levels for the perception of motion still could be observed, after a postoperative period of 18 moths or more movement sense was not different from normal, uninjured shoulders. In conclusion, our study gives evidence for a proprioceptive deficit with anterior shoulder instability which improves significantly after arthroscopic labrum repair. The restitution of proprioceptive abilities, however, seems to be a time dependent process.
Traumatic instability of the sternoclavicular joint is a rare diagnosis. It is usually treated by different bandaging techniques without the possibility of early functional aftercare. In the period between 1 January 1996 and 31 December 1998, a total of eight patients with unstable sternoclavicular joints requiring surgical treatment were treated with Balser plates. The population comprised seven anterior and one posterior dislocations. The results achieved with this alternative treatment option, which offers the advantage of enabling early functional aftercare, are presented. Seven of eight patients were available for follow-up. The eighth patient moved from the area. The Constant Score ranged between 84 and 100 points (average 89 +/- 6.6).
Instability of the glenohumeral joint can be associated with anteroinferior capsulolabral rupture. To understand its static stabilizing effect better, the collagen fiber orientation of the inferior glenohumeral ligament (IGHL), a component of the anteroinferior capsulolabrum, was studied with a small angle light scattering technique. Three rectangular samples (approximately 11 x 6 mm) were excised from the axillary pouch, one from the anterior band (AB) of the IGHL and one control sample from the long head of the biceps tendon of 7 cadaveric shoulders. The small angle light scattering technique scans the tissue with a helium-neon laser beam and quantifies the fiber alignment based on the resultant scattering pattern. The fiber orientation was quantified by an orientation index, defined as the angle within which 50% of the fibers lie. The axillary pouch had a random orientation, whereas the AB-IGHL was random with some regions of localized alignment. The percentage of tissue with an orientation index range of 25 degrees to 45 degrees was 23.2% +/- 8.5% and 29.0% +/- 13.1% for the axillary pouch and the AB-IGHL, respectively, whereas that for the long head of the biceps tendon was 61.6% +/- 15.2%. This suggests that the collagen fibers in the IGHL are not highly aligned and the anteroinferior capsulolabrum can be modeled as a continuous sheet. Moreover, a biomechanical evaluation of the anteroinferior capsulolabrum that investigates the possibility that the mechanical properties may be directionally independent should be conducted.
Traumatic instability of the sternoclavicular joint is a rare condition. It can be treated by surgical cerclage fixation, which necessitates postoperative immobilization, an approach preventing early postoperative functional rehabilitation. Balser plate stabilization is a therapeutic alternative that does not require extended periods of immobilization. From January 1, 1996, to December 31, 2000, a total of 10 trauma patients with unstable sternoclavicular joints (Allman grade III) requiring surgical management were treated with Balser plate stabilization to allow early physiotherapy. The population included 7 patients with anterior dislocations, 2 with posterior dislocations, and 1 with medial epiphysiolysis in addition to posterior dislocation. Implants were removed from 9 patients after 3 months and 1 patient after 2 months. One year or longer after the procedure, 9 of 10 patients were available for follow-up; 1 patient had moved. The results achieved with this alternative treatment are excellent. There were no cases of redislocation. The only surgical complication was a seroma that required surgical drainage. One patient had arthrosis develop. Outcome was assessed with Constant (range, 84-100; mean, 90.2 +/- 6.6) and DASH (disabilities of the arm, shoulder, and hand) (range, 4.1-16.6; mean, 8.4 +/- 1.4) scores. For the rare case of sternoclavicular joint dislocation requiring open surgical reduction and stabilization, the Balser plate technique is reliable, permits early movement, has good postoperative results, and compares favorably with alternative methods.
Seven hundred and fifty normal thumbs were examined to determine the normal range of radioulnar mobility of the metacarpophalangeal joint with the joint in full extension, 15 degrees of flexion, and full flexion. Full flexion was the position of greatest stability. Twenty-five adult unembalmed cadaver thumbs were examined to determine the optimal position for testing the metacarpophalangeal joint for ulnar collateral ligament stability. When radial stress was applied to the metacarpophalangeal joint of 20 specimens after cutting the adductor aponeurosis and capsule, minimal ulnar instability was found. However, further sectioning of the ulnar collateral ligament revealed marked ulnar instability most significantly when the thumbs were examined in full metacarpophalangeal flexion. Finally, division of the adductor aponeurosis, dorsal capsule, ulnar collateral ligament, accessory collateral ligament, and volar plate resulted in complete instability of the metacarpophalangeal joint in all positions tested.