Laxity of the elbow after experimental excision of the radial head and division of the medial collateral ligament. Efficacy of ligament repair and radial head prosthetic replacement: a cadaver study.

We studied the stabilising effect of prosthetic replacement of the radial head and repair of the medial collateral ligament (MCL) after excision of the radial head and section of the MCL in five cadaver elbows. Division of the MCL increased valgus angulation (mean 3.9 +/- 1.5 degrees) and internal rotatory laxity (mean 5.3 +/- 2.0 degrees). Subsequent excision of the radial head allowed additional valgus (mean 11.1 +/- 7.3 degrees) and internal rotatory laxity (mean 5.7 +/- 3.9 degrees). Isolated replacement of the radial head reduced valgus laxity to the level before excision of the head, while internal rotatory laxity was still greater (2.8 +/- 2.1 degrees). Isolated repair of the MCL corrected internal rotatory laxity, but a slight increase in valgus laxity remained (mean 0.7 +/- 0.6 degrees). Combined replacement of the head and repair of the MCL restored stability completely. We conclude that the radial head is a constraint secondary to the MCL for both valgus displacement and internal rotation. Isolated repair of the ligament is superior to isolated prosthetic replacement and may be sufficient to restore valgus and internal rotatory stability after excision of the radial head in MCL-deficient elbows.

[Prognostic factors in soft tissue sarcomas. Experiences from the Sarcoma Center in Aarhus]. / Prognostiske faktorer ved bløddelssarkomer. Erfaringer fra Sarkomcentret i Arhus.

In the present study, the outcome, patterns of local recurrence and survival, as well as prognostic factors, were evaluated in patients surgically treated for soft tissue sarcomas. Between January 1979 and July 1993, 316 consecutive patients were referred to the Sarcoma Centre in Aarhus with localised malignant soft tissue sarcoma of the extremities or trunk. There were 161 men (51%) and 155 women (49%), the median age was 56 years (1-94). Histologically 52 patients (16%) had a grade I, 60 patients (19%) a grade 2 and 204 patients (65%) a grade 3A or 3B tumour. The five-year local recurrence rate was 18% and the five-year survival rate was 75%. Multivariate analysis indicated the following variables as independent unfavourable factors for local recurrence: extracompartmental location, histological high-grade (i.e. histologically highly malignant) local excision, no adjuvant radiotherapy and intralesional/marginal excision. Independent unfavourable factors for survival were advanced age, extracompartmental location, histological high-grade, lower extremity location and large tumour size. Based on these variables, a prognostic model was made.

Functional and magnetic resonance imaging evaluation after single-tendon rotator cuff reconstruction.

The aim of this study was to investigate tendon integrity after surgical repair of single-tendon rotator cuff lesions. In 31 patients, 31 single-tendon repairs were evaluated. Thirty-one patients were available for clinical assessment and magnetic resonance imaging (MRI) at follow-up. A standard series of MR images was obtained for each. The results of functional assessment were scored according to the system of Constant. According to MRI evaluation, 21 (68%) patients had an intact or thinned rotator cuff and 10 (32%) had recurrence of a full-thickness cuff defect at follow-up. Patients with an intact or thinned rotator cuff had a median Constant score of 75.5 points; patients with a full-thickness cuff defect had a median score of 62 points. There was no correlation between tendon integrity on postoperative MR images and functional outcome. Patients with intact or thinned cuffs did not have significantly better functional results than patients with retorn cuffs. Because of the presence of metal artifacts and the difficulty in distinguishing postoperative scar tissue from partial tears or thinning, MRI is of minor diagnostic value in assessing the shoulder after cuff repair. However, full-thickness tears are readily diagnosed after operation with MRI.

Self-training versus physiotherapist-supervised rehabilitation of the shoulder in patients treated with arthroscopic subacromial decompression: a clinical randomized study.

In a controlled clinical prospective study, 43 consecutive patients (43 shoulders) with subacromial impingement resistant to conservative therapy and without full-thickness rotator cuff tears underwent arthroscopic subacromial decompression. The patients were randomized to either self-training or physiotherapist-guided rehabilitation for immediate postoperative rehabilitation. Postoperative follow-up was performed by an independent observer after 3, 6, and 12 months. With the use of the Constant score for evaluation of functional outcome, patients training themselves improved from a mean 53 points (range 26 to 81 points) to a mean 79 points (range 45 to 100) points after 12 months. Physiotherapist-supervised patients improved from a mean 54 points (range 20 to 90 points) to a mean 80 points (range 40 to 100 points). The self-training patients returned to work after a mean 8.5 weeks (range 1 to 14 weeks), whereas the physiotherapist-supervised patients returned to work after a mean 8 weeks (range 3 to 13 weeks). No statistical difference was found between the 2 rehabilitation methods. This study was unable to show any beneficial effect of physiotherapist-supervised rehabilitation after arthroscopic subacromial decompression of the shoulder.

Late results of total shoulder replacement in patients with rheumatoid arthritis.

Rheumatoid arthritis of the shoulder is a progressive and destructive joint disease, and similar to arthritis in other joints, progression of the disease is unpredictable and may stop at any stage of involvement. Between 1983 and 1996, more than 500 shoulder prostheses were implanted in patients at the authors' institution. Total shoulder replacement yields satisfactory short and long term results even in patients with severely destructed joints. Pain relief is reliable and significant as reported in short and long term studies. In most patients the functional result is good or acceptable. Although range of motion is only slightly increased, a satisfactory overall range of motion is achieved by most patients because of the unaffected scapulothoracic motion. However, deteriorating results, emphasizing the complexity of shoulder arthroplasty, were seen with increasing observation time in patients with rheumatoid arthritis. Proximal migration of the humeral prosthesis attributable to rotator cuff failure, with secondary eccentric glenoid loading and progressive loosening, is latent in patients with chronic progressive rheumatoid disease and was by far the most common complication (42%) in the present series.

The medial collateral ligament of the elbow joint: anatomy and kinematics.

Eighteen osteoligamentous elbow joint specimens were included in a study of the medial collateral ligament complex (MCL). The morphologic characteristics of the MCL were examined, and three-dimensional kinematic measurements were taken after selective ligament dissections were performed. On morphologic evaluation the MCL is divided into the anterior bundle and the posterior bundle. The anterior bundle can be divided into anterior and posterior bands. The maximum valgus and internal rotatory instability after transection of the anterior band, 11.7 degrees and 11.2 degrees, respectively, were found at elbow flexions of 30 degrees and 40 degrees. Severance of the entire anterior bundle produced major valgus and internal rotatory laxity through the complete flexion arc of maximal 14.2 degrees and 18.5 degrees, respectively, at 70 degrees and 60 degrees of elbow flexion. Cutting both the posterior band and the posterior bundle resulted in only internal rotatory laxity of maximal 7.2 degrees at 130 degrees of elbow flexion. This study defines the anterior band as the primary constraint to valgus and internal rotatory forces, the posterior band as the secondary, and the posterior bundle as the tertiary constraint. The MCL was observed to be a complex of ligamentous fibers rather than individual bands that stabilizes the joint against valgus and internal rotatory forces.

Frozen shoulder: arthroscopy and manipulation under general anesthesia and early passive motion.

During a 15-month period, 24 patients with arthroscopically verified frozen shoulders were treated with manipulation while under general anesthesia and early passive motion. The minimum follow-up was 12 months, and the average duration from onset of the disease until treatment was 8 months. All patients had moderate to severe pain, and the average range of motion was less than 40% of the opposite shoulder. During the follow-up period, 75% of the patients obtained normal or almost full range of motion, and 79% had slight pain or no pain at all. Eighteen (75%) patients returned to work 9 weeks (mean) after treatment. There was no relationship between the end result and the initial pathologic condition. We believe that manipulation combined with arthroscopy is an effective way of shortening the course of an apparently self-limiting disease and should be considered when conservative treatment has failed.

Posterolateral elbow joint instability: the basic kinematics.

Thirty-five osteoligamentous elbows were included in a study on the kinematics of posterolateral elbow joint instability during the pivot shift test (PST) before and after separate ligament cuttings in the lateral collateral ligament complex (LCLC). Division of the annular ligament or the lateral ulnar collateral ligament caused no laxity during the PST. Division of the lateral collateral ligament caused maximal laxity of 4 degrees and 23 degrees during forced PST in valgus and external rotation (supination), respectively. Cutting of the LCLC at the ulnar or the humeral insertion was necessary for any PST stressed elbow joint laxity to occur. Total division of the LCLC induced a maximal laxity of 7.9 degrees and 37 degrees during forced PST in valgus and external rotation (supination), respectively. This study suggests the lateral collateral ligament to be the primary soft tissue constraint to PST stress and the annular ligament and the lateral ulnar collateral ligament to be only secondary constraints. This study indicates that the integrity of the medial collateral elbow ligaments should be evaluated during forced valgus in pronation or neutral forearm rotation. Furthermore an isometric lateral collateral ligament reconstruction was shown to correct the joint laxity introduced by total LCLC transection.

Prognostic factors in soft tissue sarcomas: the Aarhus experience.

In the present study, the outcome, patterns of local recurrence and survival, as well as prognostic factors, were evaluated in patients surgically treated for soft tissue sarcomas. Between January 1979 and July 1993, 316 consecutive patients were referred to the Sarcoma Centre in Aarhus with localised malignant soft tissue sarcoma of the extremities or trunk. If possible, the patients were treated with a limb-sparing resection, primarily by use of a wide excision. 50 patients received adjuvant radiotherapy. There were 161 men (51%) and 155 women (49%) median age 56 years (range 1-94 years). 94 patients (30%) had tumours in the trunk, including shoulder and buttock lesions, 163 (52%) in the lower extremity and 59 (19%) in the upper extremity. 52 patients (16%) had grade 1 tumour, 60 (19%) grade 2 and 204 (65%) grades 3A-3B. The 5-year local recurrence rate was 18% and the 5-year survival rate was 75%. Multivariate analysis indicated the following variables as independent unfavourable factors for local recurrence: extracompartmental location, histological high grade, local excision, no adjuvant radiotherapy and intralesional/marginal excision. Independent unfavourable factors for survival were advanced age, extracompartmental location, histological high grade, lower extremity location and large tumour size. If the variable local recurrence was included in the analysis, it was found to have a very strong influence on survival. Based on these variables, a prognostic model was developed.

The relation between the position of the glenohumeral joint and the intraarticular pressure: an experimental study.

Intraarticular pressures of the glenohumeral joint were measured in 15 cadaveric shoulders during passive movement of the humerus and under various inferiorly directed loads on the humerus. With a fiber-optic transducer-tipped catheter and an airtight connector, the basic intraarticular pressure was measured directly without injection of any physiological saline solution into the joint before measurement. The initial intraarticular pressures were all negative with a mean value of -67.8mm Hg. During abduction-adduction movement the minimal intraarticular pressure was measured at 20 degrees of humeral abduction. During rotation the minimal intraarticular pressure was observed at neutral humeral rotation. The intraarticular pressure decreased nearly linearly with increasing inferior load on the humerus. These results indicate that the intraarticular pressure takes part in stabilization of the glenohumeral joint, and the negative intraarticular pressure of the glenohumeral joint induces the maximal stabilizing effect at 20 degrees of humeral abduction and neutral humeral rotation.

[Arthroscopic subacromial decompression]. / Artroskopisk subakromial dekompression.

The aim of this prospective study was to evaluate the results of arthroscopic subacromial decompression (ASAD) in the treatment of impingement syndrome in patients without full thickness rotator cuff tears. Sixty patients (64 operative procedures) underwent ASAD during the study period; 37 men and 23 women, average age 46 years (range 28-63), average duration of symptoms 37 months (range 8-132). Patients with calcifying tendintis were not included. Evaluation preoperatively and one year postoperatively included: Constant score, clinical examination and radiological evaluation (supraspinatus outlet view). All follow-up examinations were done by an independent observer. Fifty-six patients (60 procedures) were available for follow-up. The average length of follow-up was 13 months (range 10-23). Forty-six patients (77%) achieved a good or excellent result according to Constant score criteria. Preoperatively twenty-four patients had applied for worker's compensation benefits (WCB). Only half of the patients in the WCB group achieved a satisfactory result, whereas 94% of the non-WCB patients had a good or an excellent result. Arthroscopic subacromial decompression is an effective procedure for the majority of patients with stage II impingement syndrome. In this study WCB claims were associated with inferior results.

Humeral head size in shoulder arthroplasty: a kinematic study.

Changes in kinematics after hemiarthroplasty of the glenohumeral joint were investigated in nine cadaveric specimens. During experiments the influence of the humeral head size on glenohumeral kinematics was evaluated. A modular prosthesis with five different head sizes and press-fit stems was used. Three-dimensional kinematic measurements during abduction and adduction from 0 degree to 70 degrees showed increased external rotation with increasing head size. Small prosthetic heads translated inferiorly and large prosthetic heads superiorly compared with the intact humeral head. During forced anterior and posterior translation the mobility is restricted with increasing head size. This study found that when a press-fit prosthesis is used, it takes 1.25 times the volume of the intact humeral head to reconstruct the kinematics of the glenohumeral joint.

Use of recombinant factor VIIa in surgery in factor-VII-deficient patients.

Patients suffering from severe factor VII deficiency may present with serious bleeding problems. No clear guidelines exist regarding therapy in such patients in case of a large bleeding or surgery. Indeed, it has been postulated that some patients with severe factor VII deficiency may never present with overt bleeding problems. However, in factor-VII-deficient patients who have previously demonstrated a clinical tendency to bleed, surgery is expected to cause excessive bleeding. We present two females suffering from a severe factor VII deficiency (FVII:C < 0.01 U mL(-1) ) with a distinct history of haemorrhagic diathesis. Due to recurrent bleeding in the past, or for circumstantial reasons, surgery was demanded over a 4-year period on a total of seven occasions. To assist haemostasis during and after joint surgery on five occasions and for embolization and subsequent removal of a large haemangioma of the occipital region, recombinant factor VIIa (NovoSeven) was utilized in doses approximating 20 µg kg(-1) b.w. every 6 h beginning immediately before surgery and continued until 30 h to 13 days postoperatively, depending of the size of the respective procedure. Using this approach, we observed normal haemostasis, and there were no signs of excessive postoperative bleeding or wound haematoma. No adverse reactions or side-effects were observed, and there were no complaints or clinical signs indicative of thrombotic complications. As judged from the clinical course of these seven minor and major surgeries, recombinant factor VIIa appears to be highly efficaceous and safe in the treatment patients with severe factor VII deficiency undergoing surgery.

Kinematics of the lateral ligamentous constraints of the elbow joint.

Thirty osteoligamentous elbow joint specimens were included in a study of the lateral collateral ligament complex (LCLC). The morphologic characteristics of the LCLC were examined, and then three-dimensional kinematic measurements were undertaken after selective ligament dissections were performed. Isolated sectioning of the annular ligament (AL) or the lateral ulnar collateral ligament (LUCL) induced only minor laxity to the elbow joint with a maximum of 2.2 degrees and 4.4 degrees during forced varus and external rotation (supination), respectively. Transsection of the lateral collateral ligament (LCL) caused a maximal laxity of 15.4 degrees and 22.8 degrees during forced varus and external rotation (supination), respectively. Combined ligament dissections showed that total transection of the LCLC at the ulnar or the humeral insertion was important for joint laxity. Total transection of the LCLC at the humeral or the ulnar insertion induced a maximal laxity of 24.5 degrees and 37 degrees during forced varus and external rotation (supination), respectively. This study suggests the AL and the LUCL are of minor importance as constraints when cut separately, whereas the LCL is a significant preventer of elbow joint laxity. The LCLC was observed to be a complex structure of ligamentous fibers rather than discreet bands. The LCLC forms a ligamentous constraint between the lateral humeral epicondyle and the ulna, stabilizing the elbow joint and forming a base for radial head stability and rotation.

Subscapular elastofibroma: a reactive pseudotumor.

Six cases of elastofibroma located in the subscapular region are reported. The age of the patients ranged from 45 to 71 years (mean 59.5 years). In three cases the symptoms were posterior shoulder pain with arm motion, and one of these also had a snapping scapula. Two cases had tumor prominence as the only symptom, and in one case the tumor was found accidentally while thoracotomy was being performed. On magnetic resonance imaging a nonencapsulated soft-tissue mass closely related to the thoracic wall and elevating the scapula was identified. At surgery the tumor was densely adherent to the periosteum of the ribs and the external fascia of the rib cage, and peripherally it proceeded into the loose connective tissue of the subscapular space. Local excision was performed. At follow-up 1 to 8 years after surgery no recurrence was observed, and all patients with painful lesions had complete relief of pain.

Lateral collateral ligament of the elbow joint: anatomy and kinematics.

The structure and kinematics of the lateral collateral ligament of the elbow joint were investigated in 10 cadaveric specimens. The lateral collateral ligament was observed to be a distinct part of the lateral collateral ligament complex. It contains posterior fibers that pass through the annular ligament and insert on the ulna. Three-dimensional kinematic measurements in different forearm rotations showed that joint puncture induced a 1 degree joint laxity significant in forced varus from 30 degrees to 80 degrees of flexion and in forced external rotation from 30 degrees to 120 degrees of flexion. Division of the posterolateral capsule caused no further laxity. Cutting the lateral collateral ligament induced a maximum laxity of 11.8 degrees at 110 degrees of flexion in forced varus and a maximum laxity of 20.6 degrees at 110 degrees of flexion in forced external rotation. The corresponding maximal posterior radial head translation was observed at 80 degrees to 100 degrees of flexion and was 5.7 mm in forced varus and 8.1 mm in forced external rotation. This study suggests the lateral collateral ligament to be an important stabilizer of the humeroulnar joint and the radial head in forced varus and external rotation. The humeroulnar stability is independent of forearm rotation.

Total shoulder replacement in rheumatoid arthritis: proximal migration and loosening.

A prospective study of 62 Neer mark II total shoulder arthroplasties performed during the period from 1981 to 1990 on 51 patients with rheumatoid arthritis was undertaken to evaluate factors associated with component loosening and proximal humeral migration. Thirty-two (51%) showed proximal migration of the humerus before surgery was performed. The mean follow-up time was 92 months (range 52 to 139 months). The results revealed proximal migration in 55% of the patients (34 shoulders), and 40% (25 shoulders) showed progressive radiographic loosening of the glenoid component. Five of 12 press-fit humeral components demonstrated progressive radiographic loosening, whereas no signs of loosening were found in 50 cemented humeral components. In spite of progressive component loosening and progressive migration, this study demonstrated good pain relief in 89% of the patients (55 shoulders) and also a significant improvement in range of movement and function. The presence of proximal humeral migration did not significantly influence the average results-neither pain relief, range of movement, abduction force, nor function. Also, component loosening did not significantly influence the average pain relief, range of movement, abduction force, or function. The risk of clinical asymptomatic loosening is a relatively late complication that is eventually followed by pronounced bone destruction related to the loose component. Long-term radiographic control of total shoulders with rheumatoid arthritis is recommended. Hemiarthroplasty with a cemented humeral prosthesis may be a better treatment in the end stage of rheumatoid arthritis of the shoulder.

[Frozen shoulder. Arthroscopy and manipulation in general anesthesia, followed by early passive mobilization]. / Frossen skulder. Artroskopi og manipulation i generel anoestesi, efterfulgt af tidlig passiv mobilisation.

Over a 15 month period 20 patients with 20 arthroscopically verified frozen shoulders were treated with manipulation under general anaesthesia and early passive motion. The study had a minimum of six months follow-up. The average duration of the disease before treatment was eight months. Prior to treatment all patients suffered from moderate to severe pain and the average range of motion was less than 40% of the normal shoulder. During the follow-up period 55% had obtained a normal or almost full range of motion and 75% suffered from only slight pain or had no pain at all. Fourteen patients returned to prior work within a mean of nine weeks after treatment. We found no relation between the end-result and the prior pathology. We believe that manipulation with arthroscopy is an effective way of shortening the course of an apparently self-limiting disease and should be considered when conservative treatment fails.