Therapeutic efficacy of corticosteroid injections in the acromioclavicular joint.

There is debate among orthopaedists about the efficacy of steroid therapy to treat painful joints. Using an uncontrolled, retrospective study, we examined the usefulness of local corticosteroid injections in thirty-one patients (twenty-four men, seven women) with isolated AC joint arthropathy. No patients had signs of impingement or rotator cuff disease. All injections were performed using a standardized technique with each patient receiving 1cc Celestone/Soluspan or Dexamethasone and 2cc Lidocaine. At an average follow-up of nineteen months, patients were asked to answer questions regarding activity of daily living, according to the American Shoulder and Elbow Surgeons (ASES) format, average level of pain, length of pain relief from steroid injection, and time to return to full activity. Four patients could not be contacted for follow-up questions and, therefore, were excluded from the study leaving twenty-seven patients. Pain and function improved in twenty-five of twenty-seven (93%) patients after injection. Mean duration of improvement was twenty days (range, two hours to three months). Two patients reported continued relief at 1.5 and two years after injection. Due to persistent, insidious pain, eighteen of twenty-seven (67%) patients underwent distal clavicle excision an average of four months after injection. Overall, twenty-two of twenty-seven (81%) patients failed to obtain long-term relief from the injection. The results of this study suggest that the administration of local corticosteroids into the AC joint may provide short-term pain relief, but does not alter the natural progression of disease.

Reliability and reproducibility of radiographic interpretation of proximal humeral fracture pathoanatomy.

Recent studies have demonstrated inconsistencies in the use of certain images for classifying proximal humerus fractures. Our purpose was to determine whether three-dimensional computed tomography or the level of expertise of the observers would improve the reliability and reproducibility of identifying specific anatomic fragments in proximal humerus fractures. Two groups of observers, nonexperts and experts in shoulder surgery, were asked to review the radiographs and three-dimensional computed tomography scans of 12 patients with proximal humerus fractures. Observers were asked to identify displaced fracture fragments, dislocation, and articular surface fractures. Both groups of observers displayed suboptimal reliability for the identification of displaced fracture fragments. The addition of three-dimensional computed tomography scans did not improve the reliability or reproducibility. Poor agreement for the purpose of classification seems to occur at the most fundamental level, the pathoanatomic description of the fracture. Inconsistencies may have been due to imprecise identification and measurement of individual fracture fragments, differing interpretations of the pathoanatomy, or both.

Use of vertebral levels to measure presumed internal rotation at the shoulder: a radiographic analysis.

Internal rotation of the shoulder is frequently measured by noting the maximal vertebral level reached by the patient's thumb, but it is not at all certain that this maneuver is strictly measuring internal rotation. We analyzed this maneuver with computed tomographic scans of the shoulder in differing positions. We also analyzed extension of the glenohumeral joint and scapulothoracic articulation with scapular lateral radiographs. Finally, we used posteroanterior radiographs to analyze elbow flexion at the limits of internal rotation behind the back. We found that maximal internal rotation behind the back occurs in approximately a 2 : 1 ratio between the glenohumeral joint and the scapulothoracic articulation. However, the scapulothoracic articulation was more significant in placing the arm behind the back, whereas the glenohumeral joint performed most of the internal rotation in front of the body. The scapulothoracic articulation assists in this motion by both extension and internal rotation of the scapula on the thorax. The limits of internal rotation behind the back are reached with a significant contribution from elbow flexion. We conclude that measuring shoulder internal rotation by the maximal vertebral level reached by the patient's thumb greatly oversimplifies the concept of internal rotation and that limitations in this motion may not be strictly due to a loss of internal rotation at the glenohumeral joint.

Hamstring muscle injuries among water skiers. Functional outcome and prevention.

Water skiing is associated with severe injuries to the proximal hamstring muscles. We wanted to define the mechanism of injury, describe the associated pathologic changes, determine the functional limitations of patients, and suggest measures to prevent injury. Twelve patients with water skiing-related hamstring injuries were included. Six patients were experienced skiers and six were novices. The mechanism of injury was identical in five of six novice skiers. Each sustained the injury while attempting to get up on one or two skis from a submerged position. In contrast, the expert skiers all sustained injury secondary to a fall while skiing. Physical examination documented evidence of complete or partial avulsion of the proximal hamstring muscle origins in all patients. In addition, six patients had magnetic resonance imaging or computed tomography scans that confirmed the location and extent of the tear. Convalescence ranged from 3 months to 1.5 years before the patient could return to vigorous activities. Seven patients (58%) returned to most of their preinjury sports, albeit at a lower level. Five patients (42%), all with complete disruptions, were unable to run or participate in sports requiring agility. Two of these patients required delayed surgical repairs because of persistent functional limitations.

Acute dislocation of the patella. A correlative pathoanatomic study.

The objective of our study was to elucidate the characteristic pathoanatomy associated with patellar dislocation and report the preliminary results of early surgical repair. Twenty-three patients with documented patellar dislocation had standard radiographs and a magnetic resonance imaging scan. Intraarticular lesions were evaluated and treated arthroscopically followed by an open exploration of the medial aspect of the knee in 16 patients. Twelve patients were observed for a minimum of 2 years after surgical repair (average, 34 months). Eleven patients returned for a follow-up examination. Magnetic resonance imaging revealed effusion (100%), tears of the femoral insertion of the medial patellofemoral ligament (87%), increased signal in the vastus medialis muscle (78%), and lateral femoral condyle (87%) and medial patellar (30%) bone bruises. Arthroscopic examination revealed osteochondral lesions involving the patella and the lateral femoral condyle in 68% of cases. Open surgical exploration revealed tears of the medial patellofemoral ligament off the femur in 15 of 16 patients (94%). After medial patellofemoral ligament repair, none of the patients experienced recurrent dislocation. Overall 58% of the results were considered to be good or excellent and 42% were fair. Fifty-eight percent of the group returned to their previous sport with no or minor limitations.

Omniflex modular femoral component. Two- to five-year results.

A prospective study was completed on 106 consecutive cementless arthroplasties (94 patients) to determine the clinical and radiographic outcome. Ninety-two hips (81 patients) had complete follow-up data. The average age was 46 years, and the average follow-up period was 41 months (24-63 months). Clinically 94% had no or slight pain. Two patients had activity-limiting thigh pain. Most patients had no or slight limp and walked without support. Patients had similar outcomes regardless of their bone type. Ninety-three percent of hips were radiographically stable. Six were loose; three of those had major intraoperative fractures. Stable stems were characterized by middle and distal zone endosteal condensation and cortical hypertrophy; these occurred primarily in the distal zones for unstable implants. Calcar resorption was noted in 38% of hips with collars and in 68% without collars (p = 0.015). Endosteal erosions were seen in six hips (6.5%) and were related only to the patient's activity level (p = 0.021). Seven hips were revised, two for delayed sepsis, one for loosening after trauma, one for intraoperative fracture, and three for aseptic loosening. The Omniflex implant system provides acceptable but not outstanding results in a wide array of femoral geometries. The early difficulty with femoral fractures has been significantly reduced by using a prophylactic cerclage cable.