Tests for posterolateral instability of the knee in normal subjects. Results of examination under anesthesia.

An apparently normal knee was examined in each of 100 subjects while they were under general or epidural anesthesia for an unrelated operation. The Lachman, anterior drawer, posterior drawer, and pivot-shift tests were negative in all knees. All knees were stable to varus and valgus stress at both 0 and 30 degrees of flexion. The external-rotation recurvatum test also was negative in all knees. A positive reversed pivot-shift sign was present in 35 per cent of the knees, suggesting that it may not signify abnormality, at least not without a negative test on the contralateral knee. The results of the posterolateral drawer test were variable, difficult to quantify, and did not always have a firm end-point. The amount of maximum external rotation of the tibia, measured from the reference line of the medial border of the foot, was extremely variable at both 30 and 90 degrees of flexion of the knee. External rotation, as determined by this reference, was slightly greater (averaging 9 degrees) at 90 than at 30 degrees of flexion. The normal range of maximum external rotation of the foot was 10 to 45 degrees at 30 degrees of flexion of the knee and 15 to 70 degrees at 90 degrees of flexion. The presence of a large angle of external rotation and a positive reversed pivot-shift sign correlated strongly with increased ligamentous laxity and mild varus alignment of the knee.

Reflex sympathetic dystrophy of the knee. Treatment using continuous epidural anesthesia.

We retrospectively reviewed the cases of fourteen patients who had reflex sympathetic dystrophy of the knee. All fourteen were hospitalized, and epidural block anesthesia was instituted with an indwelling catheter for an average of four days, during which continuous passive motion, manipulation (as necessary), stimulation of muscles, and alternating hot and cold soaks were used. The average length of follow-up was thirty-two months. Eleven patients had complete resolution of the symptoms, two had sufficient intermittent aching with changes in the weather to need medication, and one had no relief. The diagnosis was confirmed if the symptoms were relieved by a lumbar sympathetic block. Pain that was out of proportion to the severity of the injury was the most consistent finding, being present in all fourteen patients. However, variation in clinical severity is characteristic of the syndrome. Eleven of the fourteen patients had had a previous patellar operation. After the onset of the symptoms, nine patients had two or more arthroscopic examinations, without notable findings. All fourteen patients had had extensive physical therapy and medical treatment before the epidural block was performed.

Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study.

We studied the gross, histological, and vascular anatomy of the glenoid labrum in twenty-three fresh-frozen shoulders from cadavera to demonstrate its cross-sectional anatomy, its microvascularity, and its attachments. The superior and anterosuperior portions of the labrum are loosely attached to the glenoid, and the macro-anatomy of those portions is similar to that of the meniscus of the knee. The superior portion of the labrum also consistently inserts directly into the biceps tendon, while its inferior portion is firmly attached to the glenoid rim and appears as a fibrous, immobile extension of the articular cartilage. The arteries supplying the periphery of the glenoid labrum come from the suprascapular, circumflex scapular, and posterior circumflex humeral arteries. In general, the superior and anterosuperior parts of the labrum have less vascularity than do the posterosuperior and inferior parts, and the vascularity is limited to the periphery of the labrum. Vessels supplying the labrum originate from either capsular or periosteal vessels and not from the underlying bone.

Snapping popliteus tendon syndrome. A cause of mechanical knee popping in athletes.

Six patients with snapping in the knee were evaluated with clinical history, examination, radiographs, and other imaging. All patients were younger than 40 years and none had an arthritic process. Onset was traumatic in three patients, spontaneous in two, and post-surgical in one. The popping was on the direct lateral aspect of the knee. A consistent examination finding was that the popping was more prominent when the knee was loaded with varus stress during passive flexion and extension cycling, and that it was easily palpated midway between the lateral epicondyle and lateral joint line. Four patients were treated nonoperatively and two had operations. Of those treated without surgery, two had spontaneous resolution of the popping, in one the popping persisted, although not symptomatic enough to require surgery, and one had surgery later. In the surgical group, one patient was treated with popliteus tendon release and one with tenodesis of the popliteus tendon to the fibular collateral ligament. Both procedures were curative and neither led to complicating problems. Follow-up information was not available for the patient with late surgery. Snapping of the popliteus tendon should be recognized as a cause of lateral popping in the knee. It is easily confused with more common sources of mechanical symptoms. Awareness will allow accurate diagnosis and treatment, avoiding unnecessary diagnostic arthroscopy.

The strength of the central third patellar tendon graft. A biomechanical study.

Thirty-seven bone-patellar tendon-bone composite grafts from the knees of 21 human cadavers were tested to failure. Average donor age was 28 years. The composites were divided into 4 groups: 3 groups with 10 grafts (5 pairs) and 1 group with 7 grafts from 6 donors. In Group 1 we tested 10- versus 15-mm wide grafts that were used without twisting; Group II, 10-mm wide grafts without twisting versus 10-mm wide grafts that were twisted 90 degrees; Group III, 10-mm wide grafts twisted 90 degrees versus 10-mm wide grafts twisted 180 degrees; and Group IV, 10- versus 7-mm wide grafts that were not twisted. The tests were performed using a newly described potting technique and clamp system and a servohydraulic testing machine with an elongation rate of 5 cm/sec. The results of this study suggest that the central third of the patellar tendon is stronger than previously reported. The mean ultimate load of a 15-mm bone-patellar tendon-bone composite was 4389 N (+/- 708); of the 10-mm wide composites, 2977 N (+/- 516); and of the 7-mm composites, 2238 N (+/- 316). Twisting the graft 90 degrees increased the strength (P < 0.05). Further twisting to 180 degrees had no significant effect compared with twisting 90 degrees. This study supports the practice of using smaller (10 mm) bone-patellar tendon-bone grafts to avoid the potential complications of patellar fracture and graft impingement in the notch.

Meniscal repair.

Over the past several decades, scientific evidence has mounted to substantiate the vital role of the meniscus in the function of the knee. Total meniscectomy is rarely indicated and the pendulum of orthopedic popular opinion has swung toward new ways to preserve the injured meniscus. This article reviews the anatomy, blood supply, and function of the meniscus and also discusses the supporting scientific evidence, decision-making processes, and techniques for meniscal repair.

Arthroscopic meniscal repair.

The advent of arthroscopy and advanced arthroscopic techniques has made meniscal repair the preferred approach for many meniscal tears. This article reviews the blood supply of the meniscus and discusses the supporting scientific evidence, decision making, and techniques for meniscal repair.

The role of group psychotherapy in the treatment of substance abusers.

A psychological model portrays substance abuse as the result of efforts to self-medicate for particularly painful affect states. Long-term psychotherapy is the treatment of choice for the hypersensitization to affects. The important role of group psychotherapy in substance-abuse treatment is discussed in light of clinical results.

Group psychotherapy with the elderly: dealing with loss and death.

Resolution of issues around loss and death are seen as an important developmental task for the elderly. Group psychotherapy can lessen social isolation and provide the opportunity to work on issues of loss and death in the here-and-now. An inpatient geriatric group conducted by the author is discussed.

Biomechanical properties of the central third patellar tendon graft: effect of rotation.

The results of this study suggest that the central third of the patellar tendon may be stronger than previously reported. The mean ultimate load of a 15-mm bone-patellar tendon-bone composite was 4389 N (+/- 709 N); of the 10-mm wide composites, 2977 N (+/- 516 N); and of the 7-mm composites, 2238 N (+/- 316 N). Twisting the graft 90 degrees increased the strength (P < 0.05). Further twisting to 180 degrees had no significant effect compared with twisting to 90 degrees. This study supports the practice of using smaller (10 mm) bone-patellar tendon-bone grafts to avoid the potential complications of patellar fracture and graft impingement in the notch, and suggests the value of rotating the graft prior to tibial fixation.

Trust.

KIE: The meaning of trust in the physician patient relationship is briefly explored in general, in the context of Britain's Gillick controversy concerning minors and contraception, and in the context of 'alternative' versus conventional medicine. Cooper defines three distinct kinds of trust: (A) an act of entrusting a physician with responsibility, (B) an assumption regarding the physician's trustworthiness, and (C) an epistemic attitude involving confidence in the physician's abilities. He also identifies language factors which confuse the distinctions between the three types of trust. Concluding with a discussion of what the two sides in the Gillick dispute mean by trust, Cooper argues that the disagreement concerns the limits of trust (A), and not (B), the trustworthiness of physicians.^ieng

High-sensitivity FM spectroscopy with a lead-salt diode laser.

We report the demonstration of near-quantum-noise-limited sensitivity with a lead-salt diode laser using FM spectroscopy and high-speed sweep integration. Using both single-tone and two-tone techniques, we demonstrated an absorption sensitivity of ~2 x 10(-7) in a 2.44-Hz bandwidth from a Doppler-broadened NO line at 1856.5 cm(-1). The sensitivity in our experiments was limited by laser excess noise, which was about four times the expected quantum-noise level.

Frequency modulation spectroscopy with lead-salt diode lasers: a comparison of single-tone and two-tone techniques.

We present a theoretical and experimental comparison of single-tone and two-tone frequency modulation (FM) spectroscopy using lead-salt diode lasers. Our analysis reveals those diode laser operating characteristics that are necessary for high sensitivity performance using either technique for IR absorption measurements. High sensitivity performance using these techniques requires laser diodes having low incidental amplitude modulation and a small variation in FM/AM phase shift over a suitable diode tuning range. Neither requirement is met with the present mesa-stripe lead-salt diode laser technology.

Two-tone optical heterodyne spectroscopy with a tunable lead-salt diode laser.

We report the demonstration of two-tone optical heterodyne spectroscopy with a tunable lead-salt diode laser. Using high-frequency modulation of the diode-laser injection current, we demonstrated a detection-sensitivity limit of 1 x 10(-5) to differential absorption from Doppler-broadened NH(3) lines in the 930-cm(-1) region. In our experiment, this limit was set by preamplifier noise and the low quantum efficiency of the photodetector. A substantial increase in sensitivity should be possible by using an improved detector, an improved preamplifier, and higher optical power.

Relationship between alexithymia and somatic complaints in a normal sample.

Utilizing the MMPI Alexithymia Scale and the Cornell Medical Index, the relationship between alexithymia and somatic complaints was investigated in a normal college sample. Although an initial analysis showed alexithymia negatively related to somatic complaints, when the tendency to deny problems on self-report measures was controlled for, the two variables were positively related. The positive relation between alexithymia and somatic complaints found for females was not found for male in this sample.