In vivo healing after capsular plication in an ovine shoulder model.

Traditionally, arthroscopic management of shoulder instability has been reserved for patients with isolated Bankart lesions without any capsular laxity or injury. To date, there are no animal studies evaluating the healing potential of capsular plication and/or capsulo-labral repair. The purpose of this in vivo animal study was to determine if the histological capsular healing of an open capsular plication simulating an arthroscopic plication is equivalent to the more traditional open capsular shift involving cutting and advancing the capsule. Twenty-six skeletally mature sheep were randomized to either an open capsular plication simulating arthroscopic plication (n = 13), or an open traditional capsular shift (n = 13). A sham operation (n = 4) was also performed involving exposure to visualize the capsule. Normal non-operated control shoulders were also analyzed. A pathologist blinded to the treatment evaluated both hematoxylin and eosin (H&E) sections and polarized light microscopy. Qualitative scoring evaluated fibrosis, mucinous degeneration, fat necrosis, granuloma formation, vascularity, inflammatory infiltrate and hemosiderin (0 to 3 points). Both the capsular plication and open shift groups demonstrated healing by fibrosis at the site of surgical manipulation. There were no statistical differences in the capsular healing responses between the two groups with regard to fibrosis, granuloma formation and vascularity. The open shift group demonstrated significantly more mucinous degeneration (p = 0.038). Fat necrosis was present in 4/13 specimens in the open shift group and none in the capsular plication specimens. Both groups demonstrated disorganized collagen formation under polarized light microscopy. There were no differences between non-operated control specimens and sham surgery specimens. Our findings support the hypothesis that histologic capsular healing is equivalent between the plication group and the open shift group. In addition, the open shift group demonstrated significantly more changes indicative of tissue injury. This basic science model confirms capsular healing after simulated arthroscopic plication, providing support for arthroscopic capsular plication in practice.

T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types.

Forty patients who had a diagnosis of multidirectional instability of forty-two shoulders had a modified Bankart operation in which a T-shaped incision was made in the anterior portion of the capsule, with advancement of the inferior flap superiorly and of the superior flap medially. All of the patients had been injured during athletic activities. Some degree of anterior labral injury was present in thirty-eight of the forty-two shoulders. Half of the patients had generalized ligamentous laxity. The patients were followed for an average of three years (range, two to seven years). Four patients had episodes of instability after the operation. Three had a single episode of posterior subluxation during throwing, one had recurrent posterior subluxation that subsequently was treated by posterior stabilization, and one had anterior subluxation while he was diving from a high board. The average loss of external rotation after the operation was 5 degrees with the arm at the side and 4 degrees with the arm abducted 90 degrees. Satisfaction of the patient was rated excellent for forty (95 per cent) of the shoulders, good for one shoulder, and fair for one shoulder. However, throwing athletes found that they were unable to throw a ball with as much speed as before the operation.

Instability of the shoulder after arthroplasty.

A replacement arthroplasty was performed in 236 shoulders at The Hospital for Special Surgery from 1984 through 1989. Ten patients (eight women and two men) from that group were identified as having instability of the shoulder at the time of follow-up, and the results for these patients were reviewed retrospectively. The ages of the patients ranged from fifty-six to seventy-nine years. The instability was anterior in seven of the patients and posterior in three. The anterior instability was caused by a rupture of the repaired subscapularis tendon. The operative treatment of the anterior instability consisted of mobilization and repair of the tendon, but three of the seven patients continued to have instability. A static stabilizer, consisting of an allograft of Achilles tendon, was inserted in these three patients, and the result was a success. The etiology of the posterior instability (three patients) was multifactorial. Treatment consisted of correction of any soft-tissue imbalance and revision of the prosthetic components as necessary. All ten patients were followed clinically and radiographically for at least two years. All of the patients had some loss of motion of the shoulder as compared with the motion before the dislocation. There were no neurovascular complications, problems related to the allografts, or any other complications. We concluded that proper balancing of the soft tissues and positioning of the prosthetic components are essential to a successful arthroplasty of the shoulder. The postoperative rehabilitation should include a physical therapy program in which the range of motion of the arm that was achieved in the operating room is not exceeded.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation.

Lesions of the superior portion of the glenoid labrum were created in seven cadaveric shoulders. The shoulders were mounted on a special apparatus attached to a servocontrolled hydraulic materials-testing device. Sequential fifty-newton anterior, posterior, superior, and inferior forces and a twenty-two-newton joint compressive load were applied to the shoulders. In addition, a fifty-five-newton force was applied to the tendon of the long head of the biceps brachii. The shoulders were tested in seven positions of glenohumeral elevation and rotation. An isolated lesion of the anterosuperior portion of the labrum, which did not involve the supraglenoid insertion of the biceps brachii, had no significant effect on anteroposterior or superoinferior glenohumeral translation, either with or without application of the fifty-five-newton force to the biceps brachii tendon. In contrast, a complete lesion of the superior portion of the labrum that destabilized the insertion of the biceps resulted in significant increases in anteroposterior and superoinferior glenohumeral translations. At 45 degrees of glenohumeral elevation, the complete lesion led to a 6.0-millimeter increase in anterior translation when the arm was in neutral rotation and to a 6.3-millimeter increase when the arm was in internal rotation; inferior translation also increased, by 1.9 to 2.5 millimeters. The increases in translation persisted despite application of a fifty-five-newton force to the long head of the biceps.

Modular hemiarthroplasty for fractures of the proximal part of the humerus.

A new biomodular prosthesis was used for the treatment of a displaced fracture of the proximal part of the humerus in twenty-two shoulders in twenty-two patients. The fractures were classified according to the Neer system; there were thirteen four-part, five three-part, and four head-splitting fractures. There were fifteen women and seven men, and the mean age was seventy years (range, forty-nine to eighty-seven years). The hemiarthroplasty was performed an average of eleven days (range, one to forty-five days) after the injury. The deltopectoral interval was used in all patients, and the prosthesis was implanted with cement in twenty of the shoulders. All of the patients participated in a supervised program of rehabilitation. The patients were followed for an average of thirty-six months (range, twenty-six to forty-nine months). Twenty of the twenty-two patients had a good or excellent result. The active forward elevation averaged 119 degrees; external rotation, 40 degrees; and internal rotation, to the twelfth thoracic vertebra. All of the patients except for the two who had a poor result had satisfactory relief of pain. The two patients who had a poor result had a successful revision with a modular prosthesis of the same design. The modular head could be removed, enabling the surgeon to gain access to the glenoid and to adjust the soft tissues. The over-all scores correlated inversely with the age of the patients and the interval from the injury to the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

A self-administered questionnaire for assessment of symptoms and function of the shoulder.

A self-administered questionnaire was designed to assess the severity of symptoms related to and the functional status of the shoulder. It includes domains of global assessment, pain, daily activities, recreational and athletic activities, work, satisfaction, and areas for improvement. Each domain is graded separately and is weighted to arrive at the total score. The over-all scale and each domain were prospectively tested for validity, reliability, and responsiveness to clinical change. One hundred patients who were seen for evaluation of the shoulder were enrolled in the study. The validity of the scale was demonstrated by moderate-to-high correlation of the domains and individual questions of the Shoulder Rating Questionnaire with those of the Arthritis Impact Measurement Scales 2. Validity was supported further by significant correlation of the scores in each domain with the level of satisfaction in that domain and by significantly lower scores in domains that patients selected as areas important for improvement. The over-all scale and each domain were internally consistent (Cronbach alpha, 0.71 to 0.90). Reproducibility was evaluated by repeated administration of the questionnaire after a mean of three days to forty patients whose condition was clinically stable. Reproducibility of the over-all questionnaire and individual domains was excellent (Spearman-Brown index, 0.94 to 0.98). Individual questions were reproducible, with a weighted kappa value of more than 0.7 for each. Responsiveness was evaluated by comparison of the preoperative and postoperative scores of thirty patients who had a satisfactory result one year after an operation on the shoulder. The over-all Shoulder Rating Questionnaire and each domain were responsive to clinical change as demonstrated by favorable standardized response means (range, 1.1 to 1.9) and indices of responsiveness (range, 1.1 to 2.0). Similar analysis performed for individual diagnostic groups supported the validity, reliability, and responsiveness of the questionnaire in each group. The self-administered shoulder questionnaire was found to be valid, reliable, and responsive to clinical change. These qualities should make it a useful instrument for the prospective assessment of the outcome of treatment of disorders related to the shoulder.

Arthroscopic acromioplasty. Technique and results.

Of forty-four patients who were treated by arthroscopic acromioplasty from July 1984 through August 1986, forty were available for analysis. The average age was 43.2 years, and 86 per cent of them had participated regularly in sports but were disabled due to symptoms of impingement. All patients had had a minimum of six months of non-operative therapy. The final diagnoses, which were based on the findings at arthroscopy and on clinical examination, plain radiographs, and arthrograms, were Stage-II impingement in twenty-four patients, a partial-thickness tear of the rotator cuff in six, and a full-thickness tear of the rotator cuff in ten. The shoulders were scored before the operation and again at follow-up. Preoperatively, thirty-six shoulders were rated as poor and four, as fair. After a minimum follow-up of twelve months (average, seventeen months), the scores had increased in all but one patient. The result was rated good or excellent in twenty-nine (73 per cent) of the forty patients: twenty of the twenty-four who had Stage-II impingement, four of the six who had a partial-thickness tear, and six of the ten who had a full-thickness tear. The over-all average time to return to work was nine days, and the average time to return to sports was 2.4 months. Of the thirty-three patients who had participated in sports, twenty-five (76 per cent) had returned to sports activity at the time of the most recent follow-up. The average time until full recovery was 3.8 months. There were no complications, and, over-all, thirty-eight (92 per cent) of the forty patients were satisfied with the result. In four patients, the result was a failure, and three of the four had a reoperation that relieved the symptoms.

Biomechanical evaluation of the medial collateral ligament of the elbow.

UNLABELLED: Anatomical dissection and biomechanical testing were used to study twenty-eight cadaveric elbows in order to determine the role of the medial collateral ligament under valgus loading. The medial collateral ligament was composed of anterior, posterior, and occasionally transverse bundles. The anterior bundle was, in turn, composed of anterior and posterior bands that tightened in reciprocal fashion as the elbow was flexed and extended. Sequential cutting of the ligament was performed while rotation caused by valgus torque was measured. The anterior band of the anterior bundle was the primary restraint to valgus rotation at 30, 60, and 90 degrees of flexion and was a co-primary restraint at 120 degrees of flexion. The posterior band of the anterior bundle was a co-primary restraint at 120 degrees of flexion and a secondary restraint at 30 and 90 degrees of flexion. The posterior bundle was a secondary restraint at 30 degrees only. The reciprocal anterior and posterior bands have distinct biomechanical roles and theoretically may be injured separately. The anterior band was more vulnerable to valgus overload when the elbow was extended, whereas the posterior band was more vulnerable when the elbow was flexed. The posterior bundle was not vulnerable to valgus overload unless the anterior bundle was completely disrupted. The intact elbows rotated a mean of 3.6 degrees between the neutral position and the two-newton-meter valgus torque position. Cutting of the entire anterior bundle caused an additional 3.2 degrees of rotation at 90 degrees of flexion, where the effect was greatest. CLINICAL RELEVANCE: Physical findings in a patient who has an injury of the anterior bundle may be subtle, and an examination should be performed with the elbow in 90 degrees of flexion for greatest sensitivity. As the anterior bundle is the major restraint to valgus rotation, reconstructive procedures should focus on anatomical reproduction of that structure. Parallel limbs of tendon graft placed from the inferior aspect of the medial epicondyle to the area of the sublimis tubercle will simulate the reciprocal bands of the anterior bundle. Temporary immobilization with the elbow in flexion may relax the critically important anterior band of the reconstruction during healing.

Reliability, validity, and responsiveness of four knee outcome scales for athletic patients.

BACKGROUND: Many patient-based knee-rating scales are available for the evaluation of athletic patients. However, there is little information on the measurement properties of these instruments and therefore no evidence to support the use of one questionnaire rather than another. The goal of the present study was to determine the reliability, validity, and responsiveness of four knee-rating scales commonly used for the evaluation of athletic patients: the Lysholm scale, the subjective components of the Cincinnati knee-rating system, the American Academy of Orthopaedic Surgeons sports knee-rating scale, and the Activities of Daily Living scale of the Knee Outcome Survey. METHODS: All patients in the study had a disorder of the knee and were active in sports (a Tegner score of 4 points). Forty-one patients who had a knee disorder that had stabilized and who were not receiving treatment were administered all four questionnaires at baseline and again at a mean of 5.2 days (range, two to fourteen days) later to test reliability. Forty-two patients were administered the scales at baseline and at a minimum of three months after treatment to test responsiveness. The responses of 133 patients at baseline were studied to test construct validity. RESULTS: The reliability was high for all scales, with the intraclass correlation coefficient ranging from 0.88 to 0.95. As for construct validity, the correlations among the knee scales ranged from 0.70 to 0.85 and those between the knee scales and the physical component scale of the Short Form-36 (SF-36) and the patient and clinician severity ratings ranged from 0.59 to 0.77. Responsiveness, measured with the standardized response mean, ranged from 0.8 for the Cincinnati knee-rating system to 1.1 for the Activities of Daily Living scale. CONCLUSIONS: All four scales satisfied our criteria for reliability, validity, and responsiveness, and all are acceptable for use in clinical research.

Evaluation of the arthroscopic valgus instability test of the elbow.

Seven fresh-frozen cadaveric elbows were used to evaluate the extent to which the medial collateral ligament must be injured before arthroscopic evidence of valgus instability is seen, the amount of ulnohumeral joint opening that does occur after such an injury, and the elbow position that maximizes visualization of this opening. While visualizing the most medial aspect of the ulnohumeral joint arthroscopically through the anterolateral portal, we sequentially sectioned the medial collateral ligament complex until all of the medial ligamentous restraints were cut. A valgus load was applied after each incision, and the extent to which the ulnohumeral joint opened was measured. Ulnohumeral joint opening was not visualized in any specimen until complete sectioning of the anterior bundle was performed. After the anterior bundle was released, 1 or 2 mm of joint opening was present in all specimens. Complete release of the medial collateral ligament led to dramatic increases in medial joint opening in all seven specimens (4 to 10 mm). Varying the angle of elbow flexion from 15 degrees to 120 degrees revealed that visualization of the medial joint opening was best at 60 degrees to 75 degrees. Finally, forearm pronation increased ulnohumeral joint opening and supination decreased joint opening in all specimens. We found that the entire anterior bundle must be sectioned before measurable and reproducible medial joint opening can occur.

Arthroscopic labral debridement. A three-year follow-up study.

UNLABELLED: This is a retrospective review of 40 patients who underwent arthroscopic labral debridement of the shoulder. All patients were active participants in sports involving use of the shoulder. All patients presented with shoulder pain. Only 40% were found to have distinct glenohumeral instability on examination. At surgery, all patients had labral injury. Ten patients had anterosuperior labral tears, 20 had anteroinferior labral tears or detachments, and 10 had posteroinferior labral tears or detachments. Outcome was assessed at a minimum of 2 years (average, 43 months) postoperatively. Overall, only 7% of the patients had significant symptomatic relief at followup. However, 72% noted relief of symptoms during the 1st year after surgery, but there was deterioration over time. CONCLUSION: Arthroscopic labral debridement is not an effective long-term solution for symptomatic relief in the overhead athlete.

Isolated closure of rotator interval defects for shoulder instability.

Fifteen patients noted at surgery to have an isolated defect in the rotator interval and no other pathologic abnormality underwent closure of the defect as an isolated procedure for recurrent instability symptoms. Intraoperative assessment of each of these shoulders after the closure demonstrated adequate stability, and no other stabilization procedures were performed. The average age of the patients was 24 years, and 10 of the 15 patients were women. Examination under anesthesia revealed increased inferior translation in all patients, as illustrated by at least a 1+ sulcus sign. The rotator interval defect averaged 2.75 cm in width and 2.3 cm in height. The rotator interval defect edges were freshened and approximated (nine patients) or imbricated (six patients), depending on the anterior capsular laxity and the degree of glenohumeral joint translation possible. Followup averaged 3.3 years (range, 2.2 to 5.3), and all patients achieved either a good or excellent result using the American Shoulder and Elbow Surgeons evaluation scale and the Rowe rating scale. Although most patients with a defect in the rotator interval require a standard stabilization procedure as a supplement to closure of the defect, approximation or imbrication of the defect as an initial step at surgery may confer adequate stability in selected patients and obviate the need for formal capsular advancement.

Arthroscopic assessment of the medial collateral ligament complex of the elbow.

The extent that the medial collateral ligament complex could be visualized by arthroscopy was determined in 10 fresh cadaveric elbows from 10 individuals. We carefully exposed the medial collateral ligament complex through a muscle-splitting incision before performing arthroscopy. The anterior and posterior bundles were identified and marked by placing 4.0 nylon sutures deep to the bundles to aid in arthroscopic visualization. A portion of the anterior bundle was visible in only one elbow and in that elbow only the most anterior 25% of the anterior bundle was seen. Attempts to visualize the anterior bundle through additional portals were unsuccessful. Varying the flexion angle of the cadaveric elbow from 0 degrees to 130 degrees also failed to improve visualization. Conversely, the entire posterior bundle, including humeral and ulnar insertion sites, could be seen in all 10 specimens using the posterior portals. We also noted that direct pressure was placed on the ulnar nerve in all specimens when the arthroscope or any arthroscopic instrument was advanced into the posteromedial gutter in contact with the posterior bundle because of its proximity immediately adjacent to the ulnar nerve. The inability to reliably see the anterior bundle and the humeral or ulnar insertion sites of this ligament may limit the value of the arthroscope when assessing medial collateral ligament injuries. Additionally, great care should be taken when using the arthroscope or other instruments in the posteromedial gutter because the ulnar nerve lies immediately adjacent to the thin posterior bundle and capsule.

Arthroscopic treatment of partial rotator cuff tears in young athletes. A preliminary report.

Forty-three athletes under age 40, more than half of which were collegiate or professional, with partial rotator cuff tears were treated arthroscopically and observed for a minimum of 24 months. By history and mechanism of injury, two main groups were identified. Group A had 14 patients with acute, traumatic injuries. All 14 had inflamed subacromial bursas, but increased glenohumeral translation and labral lesions were uncommon. Twelve patients (86%) had satisfactory postoperative results and nine (64%) returned to preinjury sports after arthroscopic subacromial decompression and tear debridement. Group B had 29 overhead athletes with insidious, atraumatic shoulder pain. They were not as successful with debridement (19 [66%] satisfactory and 13 [45%] return to preinjury sports). Within Group B, three subgroups were identified based on the examination under anesthesia and subacromial inflammation. Group B1 (8 patients) had normal-appearing subacromial spaces and often increased anterior glenohumeral translation with posterior labral tears. These patients did poorly after arthroscopic tear debridement (3 [38%] satisfactory and 2 [25%] return to sports). Group B2 (12 patients) had inflamed subacromial bursas and increased glenohumeral translation. This group had marginal results with debridement (7 [58%] satisfactory and 6 [50%] return to sports). Group B3 (9 patients) with subacromial inflammation, yet without increased glenohumeral translation, had excellent pain relief (100%) but less than half (4) returned to preinjury sports.

Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum followup.

Thirty-seven of 41 consecutive patients with recurrent anterior instability of the shoulder were retrospectively observed for a mean of 5.6 years (range, 4 to 10) after an arthroscopic stabilization procedure had been performed. The operative technique involved the use of transglenoid sutures to repair the capsule and labrum. According to the criteria established by Rowe, 27 patients (74%) had good or excellent results, and 3 patients (7%) were graded as fair. Seven patients (19%) developed recurrent instability after the procedure and had failed results. Failure rates were equal in patients with a history of recurrent dislocation and those with recurrent subluxation. Absence of a Bankart lesion at operation was associated with postoperative instability (P = 0.03). The presence or size of humeral head defects did not influence the result. Eight of 12 athletes who engaged in sports requiring repetitive overhead shoulder motion returned to full activity, and none of the 12 developed instability after operation. Four of the 13 patients who participated in contact sports or recreational skiing developed postoperative instability (P = 0.21). All failures occurred within 2 years of the procedure.

A muscle-splitting approach to the ulnar collateral ligament of the elbow. Neuroanatomy and operative technique.

The standard surgical approach for repair or reconstruction of the ulnar collateral ligament of the elbow involves lifting off of the tendon of the common flexor bundle at its origin on the medial epicondyle. However, a more limited muscle-splitting approach may be feasible. A muscle-splitting approach is less traumatic to the flexor-pronator muscle mass, and it could decrease operative time and lessen immediate morbidity after surgery. A proposed muscle-split through the common flexor bundle extends from the medial humeral epicondyle to a point distal to the tubercle of the ulna such that repair or reconstruction can be performed on the ulnar collateral ligament. To examine the feasibility of this approach, we performed a study combining anatomic dissections with clinical observations. We dissected 15 fresh-frozen adult cadaveric elbows to examine the neuroanatomy of the medial side of the elbow. All pertinent nerves were identified and mapped. From these data, we defined a "safe zone" for a muscle-splitting approach to the ulnar collateral ligament that allows adequate room for repair or reconstruction of the ligament without risking denervation of the surrounding musculature. The safe zone extends from the medial humeral epicondyle to approximately 1 cm distal to the insertion of the ulnar collateral ligament on the tubercle of the ulna. Twenty-two patients with ulnar collateral ligament tears underwent either a direct repair or a reconstruction of the ligament using the proposed muscle-splitting approach. With a minimum followup of 1 year, there was no clinical evidence of muscle denervation. From the combined anatomic study and clinical data, we believe that a less traumatic muscle-splitting approach to the ulnar collateral ligament affords a safe and simple surgical approach for repair or reconstruction of the ligament.

Traumatic tears of the subscapularis tendon. Clinical diagnosis, magnetic resonance imaging findings, and operative treatment.

The study population consisted of 14 shoulders in 13 consecutive patients with surgically confirmed isolated subscapularis tendon tears. In all but three patients, the mechanism of injury was traumatic hyperextension or external rotation of the abducted arm. All patients reported pain and weakness in the affected shoulder. Physical findings revealed limited passive range of motion at maximal internal and external rotation due to pain, weakness of internal rotation of the shoulder, and tenderness in the region of the intertubercular groove. However, these findings did not conclusively point to the subscapularis tendon as the site of injury. Preoperative interpretation of magnetic resonance imaging studies was used to diagnose tears of the subscapularis tendon in 14 shoulders and biceps tendon subluxation or dislocation in 6 shoulders. On arthroscopic examination, one patient was found to have a partial-thickness tear that was treated with arthroscopic debridement. Six shoulders had full-thickness tears of the subscapularis tendon, and seven shoulders had full-thickness tears associated with concomitant biceps tendon pathologic conditions, including subluxation, dislocation, or rupture. The full-thickness subscapularis tendon tears were repaired via an open anterior approach to the shoulder through the deltopectoral groove. Associated biceps tendon injuries were treated with tenodesis of the tendon to the intertubercular groove. Our early followup results have shown that, with proper diagnoses and surgical treatments, patients have greatly decreased pain and marked improvement in shoulder function.

An aneurysm involving the axillary artery and its branch vessels in a major league baseball pitcher. A case report and review of the literature.

Baseball pitchers appear to be prone to aneurysms of the axillary artery and its branches. The cause is probably related to repetitive compression of or tension on the vessels at the level of the pectoralis minor muscle and the humeral head, which is exacerbated by the pitching motion. The incidence of aneurysms of the axillary artery and its branches among pitchers and other athletes is not known, nor is it clear whether pitchers who are at high risk of vascular injury can be identified before irreversible damage to the vessels has occurred. Perhaps patients who have documented compression or occlusion of the vessel with the arm in the abducted, externally rotated position are at higher risk. Screening pitchers to identify those with axillary artery compression, aneurysm, or thrombosis has also not been shown to be effective. Certainly, many pitchers will have some level of compression of the axillary artery with their arm in the pitching position but will never develop any clinical abnormality requiring treatment. Screening would therefore probably lead to a high false-positive rate. It is clear, however, that pitchers who complain of ischemia-type symptoms such as early fatigue or who have evidence of emboli require a complete evaluation to rule out any abnormality of the axillary artery or one of its branches. Orthopaedic surgeons who see pitchers and other athletes involved in repetitive overhead motions need to be aware of this disorder so that they order the appropriate tests and obtain a vascular consultation--and make a prompt diagnosis. Treatment will vary depending on the type of lesion and on which vessel or vessels are involved, and should be decided on by the team of surgeons treating the patient.

Noncontrast magnetic resonance imaging of superior labral lesions. 102 cases confirmed at arthroscopic surgery.

Previous studies report that noncontrast magnetic resonance imaging is limited in the evaluation of the superior glenoid labrum. From our magnetic resonance imaging database of 2552 patients, we prospectively identified 104 patients with superior labral lesions who subsequently went on to arthroscopic surgery. Magnetic resonance images were assessed to identify fraying, flap tears, bucket-handle tears, or displaced flap of fibrocartilage. The biceps tendon was also evaluated. Patients were categorized according to Snyder's classification, and the findings on the magnetic resonance images were correlated with surgical findings. One hundred of the 104 tears suspected on the images were confirmed at surgery. There were four false-positives and two false-negatives, the former reflecting one normal labrum, two meniscoid-type labra, and one sublabral foramen. With arthroscopic surgery as the standard, magnetic resonance imaging had a sensitivity of 98.0% (100 of 102), a specificity of 89.5% (34 of 38), and an accuracy of 95.7% (134 of 140) for detection of superior labral lesions. We concluded that high-resolution noncontrast magnetic resonance imaging can accurately diagnose superior labral lesions and aid in surgical management.

An evaluation of the shoulder relocation test.

The purpose of this study was to evaluate the sensitivity, specificity, negative and positive predictive values, and accuracy of the shoulder relocation test in 100 patients who underwent shoulder surgery. Based on operative data and examination under anesthesia, the diagnoses were grouped into six categories: anterior instability (without cuff disease), posterior instability, rotator cuff disease (without associated anterior instability), acromioclavicular disorder, osteoarthrosis, and instability of the biceps tendon. The test was performed on the day of surgery by placing the arm in a position of 90 degrees of humerothoracic abduction and 90 degrees of external rotation (90 degrees/90 degrees). Patient responses of pain and apprehension (considered separately) were assessed in this position both with and without application of an anterior force to the proximal humerus. The relocation test assessed diminution of pain and apprehension after application of a posteriorly directed force to the proximal humerus relative to the position of 90 degrees/90 degrees alone and to the position of an anterior force being applied to the proximal humerus. Overall, 63 patients reported pain with 90 degrees/90 degrees; 74 reported pain when an anterior force to the proximal humerus was applied: the anterior instability group alone had 46 and 63 reports of pain, respectively; the rotator cuff group alone had 82 and 88 reports of pain, respectively. The only positive responses for apprehension were in the anterior instability group, of which 63% had apprehension with 90 degrees/90 degrees alone and 74 had apprehension when an anterior humeral force was applied.(ABSTRACT TRUNCATED AT 250 WORDS)