Fractures of the radial head and neck in children.

In thirty-three children with fractures of the radial head or neck, and with a minimum follow-up of two years, fractures of the radial neck were most common. The proximal radial epiphysis was usually closed by the age of fifteen years. The older children in the series had the worst prognosis, as did children with other associated upper-extremity injuries, usually on the medial aspect of the elbow. The results were best if treatment was initiated early, and closed reduction usually gave the most satisfactory results. Roentgenograms of the involved elbow were often abnormal even with a good clinical result, but the long-term result in such situations is uncertain.

Frozen shoulder. A long-term follow-up.

Sixty-two patients (sixty-eight shoulders) who had been treated non-operatively for idiopathic frozen shoulder were evaluated subjectively and objectively at two years and two months to eleven years and nine months of follow-up (average, seven years). Thirty-one (50 per cent) of these patients still had either mild pain or stiffness of the shoulder, or both. The range of motion averaged 161 degrees of forward flexion, 157 degrees of forward elevation, 149 degrees of abduction, 65 degrees of external rotation, and internal rotation to the level of the fifth thoracic spinous process. Thirty-seven (60 per cent) of the sixty-two patients still demonstrated some restriction of motion as compared with study-generated control values (calculated as the average motion, in each plane, for the thirty-seven unaffected shoulders of the patients who had unilateral disease). Ten patients had restriction of forward flexion; eight, of forward elevation; seventeen, of abduction; twenty-nine, of external rotation; and ten, of internal rotation. However, when the motion of each affected shoulder of thirty-seven patients who had unilateral involvement was compared with that of the unaffected contralateral shoulder, eleven (30 per cent) demonstrated some restriction. None of these patients had restriction of forward flexion; two had restriction of forward elevation; two, of abduction; seven, of external rotation; and seven, of internal rotation. The patients who had substantial restriction in three planes or more were thirteen times more likely to be men (p greater than 0.05). Marked restriction, when it was present, was most commonly in external rotation. Only seven patients (11 per cent) reported mild functional limitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of tears of the rotator cuff in athletes.

Forty-five athletes with either a partial or a complete tear of the rotator cuff were treated with anterior acromioplasty and repair of the tear. The minimum duration of follow-up was twenty-four months (average, forty-two months). Thirty patients had an incomplete tear and fifteen had a complete tear. Postoperatively, thirty-nine (87 per cent) of the patients stated that they were improved compared with their preoperative status, although only thirty-four patients (76 per cent) felt that they had a significant reduction of pain postoperatively. Objectively, twenty-five (56 per cent) of the patients were rated as having a good result, which allowed them to return to their former competitive level without significant pain. Twelve (41 per cent) of the twenty-nine athletes who had been involved in pitching and throwing returned to their former competitive status. Seven (32 per cent) of the twenty-two pitchers and throwers who had been active at a professional or collegiate level returned to the same competitive level. In our experience, a repair of the rotator cuff combined with an acromioplasty in a young athletic population provides satisfactory relief of pain but does not guarantee that the patient will be able to return to his or her former competitive status in all sports.

The coracoid transfer for recurrent anterior instability of the shoulder in adolescents.

Thirty-six shoulders with recurrent anterior dislocation or subluxation in thirty-four adolescent patients were treated with a modified Bristow procedure. The average length of follow-up was five years and ten months. Postoperatively, two patients had recurrent anterior subluxation on one occasion and none had recurrent anterior dislocation. The average loss of external rotation was 10 degrees. Despite the fact that young patients have a high rate of recurrence after anterior dislocation or subluxation of the shoulder, the modified Bristow procedure is an effective method of treating recurrent anterior instability of the shoulder in adolescents.

Patellar tendon length change after anterior cruciate ligament reconstruction using the midthird patellar tendon.

The purpose of this study was to determine if use of the midthird patellar tendon autograft contributes to or causes patellar tendon shortening or patella baja in anterior cruciate ligament reconstruction. Thirty-six patients undergoing arthroscopically assisted midthird patellar tendon autograft anterior cruciate ligament reconstruction were studied prospectively. Intraoperative patellar tendon length changes were measured. Half of the patients had the tendon defect closed and half had it left open (closing peritenon only). Radiographic tendon length changes and patella baja were assessed using Insall-Salvati and Blackburne-Peel ratios measured on 45 degrees lateral knee radiographs using an adjustable polypropylene jig. Bilateral films were obtained preoperatively and at 2 weeks, 3 months, and 6 months postoperatively. No patients demonstrated evidence of patellar tendon shortening greater than the 5.5% measurement error. Tendon defect closure resulted in negligible tendon shortening intraoperatively, averaging 2.28% (1.11 mm). Of the 18 patients whose defects were closed, 5 showed no shortening. The remaining 13 patients had measurable tendon shortening less than 4% (2 mm). No patients developed patella baja.

A biomechanical analysis of anterior cruciate ligament reconstruction with the patellar tendon. A two year followup.

Eleven patients, 2 years after ACL reconstruction with a patellar tendon graft, returned for follow-up testing consisting of: 1) subjective assessment and functional analysis, 2) objective examination for residual ligamentous instability, 3) isokinetic quadriceps and hamstrings strength assessment, 4) radiographic assessment, 5) instrumented measurement of anterior shear displacement via a knee arthrometer, and 6) force plate and film analysis while performing cutting maneuvers in a laboratory setting. All 11 patients had been tested preoperatively through all steps except the fifth. The group subjectively rated the postoperative knee as 83% of the preinjury status, an increase from a 53% mean prior to reconstruction. Six of 11 patients were able to return to their full preinjury level of competition, with or without a brace. Four patients had positive drawer tests, five had positive Lachman examinations, and all subjects had negative pivot shifts. Significant quadriceps torque deficits remained (P less than 0.0005), with the postoperative knee extensors approximately 85% of the contralateral limb. The involved limb hamstrings were equal in strength to the nonoperated limb. Radiographic evaluation revealed four, five, and four patients with positive findings of the patellofemoral joint, medial joint space, and lateral joint space, respectively. Only one patient had normal radiographs. Instrumented knee laxity testing revealed the operated knee to be significantly looser only during maximum passive displacement (7.2 mm versus 5.3 mm, P less than 0.01) and not during the other measurements. Biomechanical analysis of the straight cut maneuver revealed no significant differences between the nonoperated and operated limbs at the 2 year postoperative mark.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous and open surgical repairs of Achilles tendon ruptures. A comparative study.

A comparative study between percutaneous repair and open surgical repair of acute spontaneous Achilles tendon ruptures in young athletic patients is presented. Twenty-seven patients with acute Achilles ruptures were evaluated objectively and with subjective questionnaires. Fifteen of the patients were treated by reconstruction with a gastrocsoleus fascial graft (followup, 4.6 years) and 12 treated by percutaneous repair (followup, 1.8 years). Subjectively, both groups were very satisfied with the results of their treatment. Cybex II dynamometer measuring strength, power, and endurance revealed no statistical significant differences between groups, even in light of the shorter followup of the percutaneous group. The percutaneous repairs demonstrated significantly more symmetry in injured/uninjured tendon size than did the open surgical repairs. Two reruptures occurred in the percutaneous group. No other complications were noted. After evaluation of both subjective and objective data we recommend percutaneous repair in the recreational athlete and in patients concerned with cosmesis. Open repair is recommended for all high-caliber athletes who cannot afford any chance of rerupture.

The Mumford procedure in athletes. An objective analysis of function.

No report in the English literature exists on objective muscle testing following the Mumford procedure (distal clavicular resection). Twenty-three athletes, including six at the professional level, were evaluated an average 3.7 years after the Mumford procedure was performed for degenerative changes after a Grade I or Grade II dislocation. All athletes were evaluated with an in depth questionnaire, physical examination, and radiographic study. Seventeen performed Cybex testing of both shoulders. All but one were satisfied with the surgery. Sixteen returned to their same level of sports activity, including five of the six professional athletes. The most common complaint of all those not achieving the previous level of sports was the inability to achieve their previous maximum bench press strength. All athletes demonstrated full motion; five exhibited painless crepitation at the acromioclavicular joint. Ten of the twenty-three exhibited increased horizontal clavicular motion. Radiographs demonstrated an average of 1.9 cm of bone resection, with varying amounts of ossification present between the remaining clavicle and acromion in eight athletes. The involved limb performed significantly more work than the sound limb in flexion (P = 0.0133) and internal rotation (P = 0.0575) at 300 deg/sec. The involved limb performed significantly more repetitions at 300 deg/sec than the sound limb in the extension plane (P = 0.0373). The sound limb was significantly stronger during extension (P = 0.0759) and flexion (P = 0.0063) at 60 deg/sec compared to the involved limb. The sound limb performed significantly more total repetitions at 300 deg/sec in the abduction-abduction plane than the involved limb (P = 0.0843).(ABSTRACT TRUNCATED AT 250 WORDS)

An EMG analysis of the shoulder in throwing and pitching. A preliminary report.

Five male subjects' throwing and pitching motions were analyzed by dynamic electromyography and high speed photography. Electrodes inserted into the deltoid and rotator cuff muscles attempted to define muscle activation patterns during the throwing and pitching cycle. The wind-up or preparation (Stage I) had no consistent pattern. Cocking (Stage II) had a sequential muscle activation pattern of first deltoid activity, followed by the S.I.T. muscles and finally by the subscapularis muscle. Acceleration (Stage III) had a lack of muscle activity, even though the arm was accelerating forward in space. Follow-through (Stage IV) was the most active stage with all the muscles firing intensely. The muscle patterns observed during the cycle were largely characteristic of attempts to decelerate the arm.

Functional analysis of untreated and reconstructed posterior cruciate ligament injuries.

Twenty patients with old ruptures of the PCL were analyzed. Ten patients were untreated, and ten patients had reconstruction of the PCL with the medial head of the gastrocnemius. The patients' gait was analyzed using high speed photography, footswitches, electromyography, and force plate. Patients were studied while walking, running, and stair-climbing. A Cybex muscle strength evaluation was also performed. Clinically, all patients had moderate to severe posterior instability. Five of the 20 patients also had posterolateral instability. Cybex testing showed quadriceps deficits in both reconstructed and untreated groups when comparing involved and uninvolved limbs. The reconstructed group also had deficits on hamstring Cybex testing. Footswitch data showed only minimal abnormalities. Gait velocity of walking was 91% of normal with a normal cadence. There was no significant difference in the single limb support times between the involved and uninvolved limbs in walking, fast walking, or running. The photometric data showed a tendency for increased knee flexion during the midstance phase of the gait cycle in comparing involved and uninvolved limbs. The knee flexion angles during midstance were similar in the patients with posterior instability when compared to the patients with the additional posterolateral instability. Force plate data showed decreased foot-floor reaction in the untreated group during terminal stance while walking. Similar findings were found in the reconstructed group during running.(ABSTRACT TRUNCATED AT 250 WORDS)

A dynamic analysis of a functional brace for anterior cruciate ligament insufficiency.

A dynamic, in vivo, functional analysis of braces designed for ACL insufficiency has never been reported. In this study, 14 athletes who had arthroscopically proven absent ACLs were evaluated in the Biomechanics Laboratory at the Centinela Hospital Medical Center. None of the ligaments were repaired or reconstructed. Footswitch, high speed photography, and force place data were recorded while the athletes performed running and cutting maneuvers with and without their custom fitted C.Ti. braces (Innovation Sports, Irvine, CA). Cybex testing, KT-1000 evaluation, and radiographs were collected for each subject. Statistical analysis showed that while performing cutting maneuvers, braced limbs generated significantly increased shear forces compared to the same limb unbraced. During straight line running, braced limbs generated significantly less lateral and aft shear forces compared to the same limb unbraced. Running velocity increased while wearing a brace for most athletes, but this was not statistically significant. As expected, the sound limb generated significantly greater shear forces than the unbraced involved limb during most cutting maneuvers. Athletes who did not achieve 80% of the Cybex (Cybex, Division of Lumex, Ronkonkoma, NY) quadriceps torque of the sound limb generated significantly more forces during cutting maneuvers while wearing their braces. The cutting angle, approach time to the cut, and time on the force plate showed no significant differences during brace wear. We conclude that the C.Ti brace allows significantly better running and cutting performances for athletes who have torn ACLs. Athletes who have not achieved 80% of quadricep strength as measured by Cybex testing showed even more improvement while wearing their braces.(ABSTRACT TRUNCATED AT 250 WORDS)

An EMG analysis of the shoulder in pitching. A second report.

This is the second report in a series of projects dealing with electromyographic (EMG) analysis of the upper extremity during throwing. Better understanding of the muscle activation patterns could lead to more effective preseason conditioning regimens and rehabilitation programs. Indwelling wire electrodes recorded the output from the biceps, long and lateral heads of the triceps, pectoralis major, latissimus dorsi, serratus anterior, and brachialis for four professional baseball pitchers. These signals were synchronized electronically with high speed film records of a fast ball. The EMG signals were converted from analog to digital records. Results showed that wind-up and early cocking phases showed minimal activity in all muscles, and such firing which occurred was of low intensity. Late cocking, which occurred after the front foot was firmly planted, showed moderate activity in the biceps. Cocking was terminated by the pectoralis major and latissimus dorsi. At this point, the trunk began to rotate forward, while the arm remained elevated and the elbow flexed. Also, the shoulder was moving to maximum external rotation. During the acceleration phase, the biceps was notably quiescent, while the pectoralis major, latissimus dorsi, triceps, and serratus anterior were all active. Muscle action at this time terminated external rotation and elbow flexion; i.e., the muscles fired as decelerators and also initiated the opposite actions for ball acceleration, internal rotation and elbow extension. Follow-through was not only a time of eccentric contraction with muscle activity decelerating the upper extremity complex, it was also an active event with the shoulder moving across the body and the elbow into extension with forearm pronation.

Repair of distal biceps tendon ruptures in athletes.

Ten athletes with distal biceps tendon ruptures that had been anatomically repaired with a double-incision techniques were reviewed to determine their functional recovery. All of the patients were men, with an average age of 40 years (range, 25 to 49). Eight of the 10 patients were weight lifters or body builders, and 7 had participated on a competitive level at some point in their athletic careers. Six injured their dominant extremity, and 4 their nondominant extremity. Isokinetic muscle testing of supination and flexion was performed in 8 patients and the results were compared to a control group. Followup averaged 50 months (range, 12 to 105). Patients uniformly graded their subjective results as excellent, with a group mean rating of 9.75 on a 10-point scale. All athletes returned to full, unlimited activity. The contour of the biceps muscle was restored in all cases. Isokinetic muscle testing demonstrated that in those patients with a repaired dominant extremity, supination strength and endurance was normal; in flexion, they had normal strength, but averaged 20% less endurance. Testing of the group that had the nondominant extremity repaired revealed a supination strength deficit of 25%, but normal endurance. Flexion strength and endurance were essentially normal in this group. Anatomic repair of a distal biceps tendon rupture gives consistently excellent subjective and good objective results in athletes, particularly for those sports with high strength demands such as weight lifting and body building. Rehabilitation of the operated arm, especially the repaired nondominant extremity, should be emphasized.

Infraspinatus muscle-splitting incision in posterior shoulder surgery. An anatomic and electromyographic study.

Standard posterior shoulder surgical approaches include infraspinatus tendon detachment and infraspinatus-teres minor interval development. Cadaveric and clinical investigation of a new infraspinatus-splitting approach to the posterior glenohumeral joint was undertaken to assess efficacy in providing exposure, preserving tendon attachment, and avoiding neurologic compromise. Infraspinatus musculotendinous and neural anatomy was examined in 20 cadavers. Four patients with posterior shoulder instability underwent posterior capsulorrhaphy through this infraspinatus-splitting approach, followed by electrodiagnostic testing. Infraspinatus muscle was bipennate in all specimens, the tendinous interval an average 14 mm inferior to the scapular spine at the glenoid rim. The infraspinatus-splitting interval bisected the posterior glenoid rim at its midpoint, whereas the infraspinatusteres minor interval crossed the glenoid rim's lower quarter. The suprascapular nerve provided sole innervation to the infraspinatus muscle in all specimens, entering the infraspinous fossa at the notch as a single trunk 22 mm medial to the glenoid rim. Minimum branching variability was observed. Electrodiagnostic testing showed no evidence of axonal damage or muscle denervation in either infraspinatus pennate bundle. Limiting infraspinatus-splitting dissection medially to 1.5 cm from the posterior glenoid rim prevents damage to any interval-crossing suprascapular nerve branches. Posterior shoulder surgery through a horizontal, longitudinal infraspinatus tendon-splitting approach provides excellent exposure of posterior capsule, labrum, and glenoid, without requiring tendon detachment or causing neurologic compromise.

Functional analysis of anterior cruciate ligament instability.

Eighteen males and two females (mean age, 26.5 years) underwent biomechanical assessment and Cybex evaluation prior to ACL reconstruction. Clinically, all patients had at least a 1+ grade with the Lachman, anterior drawer, and pivot shift tests, the majority being graded as 2+. Footswitch, high speed photography, force plate, and indwelling wire electrode data were collected while each subject performed free and fast walking, running, cutting, and stair climbing activities. During walking, single limb support times did not differ between the subject's involved and uninvolved limbs. Knee joint angles were similar between limbs during walking, running, and stair climbing maneuvers. Dynamic EMG tracings during walking demonstrated similar quadriceps and calf activity between limbs, while greater variation in hamstring firing was evident among subjects. During running, the involved limb had a longer duration of medial hamstring activity compared to the lateral hamstring. No significant differences were seen in either vertical or sagittal shear forces during free walking. During fast walking, higher midstance vertical forces (F2) were present in the involved limb (P less than 0.05). During running, the involved limb experienced lower vertical forces (P less than 0.05), while both anterior and posterior sagittal shear differences were insignificant. Straight cut maneuvers demonstrated significantly lower lateral shear and vertical forces in the involved limb (P less than 0.05). Lower lateral and sagittal shear forces in the involved limb (P less than 0.01 and P less than 0.05, respectively), combined with a reduced angle of the cut during the cross-cut maneuver, may be the first means to assess the functional pivot shift phenomenon ever documented.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparative electromyographic analysis of the shoulder during pitching. Professional versus amateur pitchers.

Dynamic, fine-wire, intramuscular electromyography (EMG) was performed on 12 different shoulder muscles in 13 normal male subjects as they pitched a baseball. Seven were major league baseball pitchers and six were amateur pitchers. The act of pitching a fast ball was filmed at 450 frames per second with the EMG signals recorded synchronously. The subscapularis, supraspinatus, and infraspinatus muscles were tested in 13 subjects, the biceps brachii muscle was tested in 12, and other shoulder muscles were tested variously among the subjects. Two groups of muscles were identified. Group I muscles, the supraspinatus, infraspinatus, teres minor, deltoid, trapezius, and biceps brachii, served primarily to position the shoulder and elbow for the delivery of the pitch. These muscles were found to have greater activity during the early and late cooking stages, with less activity during acceleration. Group II muscles accelerated the arm and baseball forward in space. These muscles, the pectoralis major, serratus anterior, subscapularis, and latissimus dorsi, had stronger activity during the propulsive phase of the pitch. The professional pitchers were able to use the muscles about the shoulder in an efficient manner to achieve greater pitching velocities. The subscapularis and latissimus dorsi muscles of Group II had stronger activity among the professionals, whereas the supraspinatus, teres minor, and biceps brachii muscles of Group I had only minimal activity. The amateurs, on the other hand, continued to use all of the rotator cuff muscles and the biceps brachii muscle of Group I through the acceleration stage of the pitch.(ABSTRACT TRUNCATED AT 250 WORDS)

Reconstruction of the lateral collateral ligament of the knee with patellar tendon allograft. Report of a new technique in combined ligament injuries.

This is a retrospective study of 10 patients with combined cruciate ligament and posterolateral instability who underwent surgical reconstruction between 1991 and 1994. All knees had at least 20 degrees increased external rotation at 30 degrees of knee flexion and from 1+ to 3+ varus instability. Five knees with posterior cruciate ligament ruptures had at least a 2+ Lachman test result. (One knee had both anterior and posterior cruciate ligament injuries). In all cases the lateral collateral ligament was reconstructed with a bone-patellar tendon-bone allograft secured with interference screws. Fixation tunnels were placed in the fibular head and at the isometric point on the femur. The cruciate ligaments were reconstructed with autograft or allograft material. The average follow-up was 28 months. Excessive external rotation at 30 degrees of flexion was corrected in all but one knee. Six patients had no varus laxity, and four patients had 1+ varus laxity at 30 degrees of flexion. The posterior drawer test result decreased, on average, to 1+, and the Lachman test result decreased to between 0 and 1+. The average Tegner score was 4.6, with five patients returning to their preinjury level of activity and four returning to one level lower. These results indicate that this is a promising new procedure for patients with instability resulting from lateral ligament injuries of the knee.

Isometry of the posterior cruciate ligament. Effects of functional load and muscle force application.

The effects of functional load and muscle force application on isometry of the posterior cruciate ligament were determined. Eight fresh-frozen cadaver knees were mounted in a custom-designed rig. A full range of motion and muscle forces were applied through the quadriceps, hamstring, and gastrocnemius tendons during a simulated static squat maneuver. The low-load isometric posterior cruciate ligament point was located 5.63 mm proximal and 0.18 mm anterior to the anatomic center of the posterior cruciate ligament origin on the femur. The high-load state, with no gastrocnemius and hamstring muscle forces applied, shifted the isometric point 6.32 mm proximal and 6.72 mm anterior (P < 0.05). Loading the hamstring and gastrocnemius muscles also shifted the isometric point (P < 0.05). This study indicated that the most isometric region of the posterior cruciate ligament femoral attachment changed significantly when functional loads and muscle forces were applied to the knee. This finding may have implications for both surgical reconstruction and rehabilitation of the posterior cruciate ligament-injured knee.

Glenohumeral joint translation after arthroscopic, nonablative, thermal capsuloplasty with a laser.

The purpose of this study was to determine whether there are changes in anterior and posterior glenohumeral translation after arthroscopic, nonablative, thermal capsuloplasty with a laser. Two anteriorly and two posteriorly directed loads were sequentially applied to the humerus of nine cadaveric glenohumeral joints, and anterior and posterior translation of the humerus on the glenoid was measured. The glenoid was rigidly fixed, and the glenohumeral joint was positioned simulating 90 degrees of shoulder abduction and 90 degrees of external rotation. Using the holmium:yttrium-aluminum-garnet laser, thermal energy was then applied to the anterior capsuloligamentous structures and anterior and posterior translation measurements were then repeated. The results showed a significant reduction in anterior and posterior translation after laser anterior capsuloplasty. Anterior translation decreased from 10.9 +/- 2.0 mm (mean +/- SEM) to 6.4 +/- 1.5 mm with the 15-N load; and from 13.4 +/- 2.1 mm to 8.9 +/- 1.8 mm with the 20-N load. Posterior translation decreased from 7.2 +/- 1.2 mm to 4.4 +/- 0.6 mm with the 15-N load and from 10.4 +/- 1.4 mm to 6.5 +/- 0.9 mm with the 20-N load. These results indicate that the holmium:yttrium-aluminum-garnet laser can be used to decrease glenohumeral joint translation and may be an effective treatment for glenohumeral joint instability.

Staple capsulorrhaphy for recurrent posterior shoulder dislocation.

Recurrent posterior shoulder dislocation or subluxation is uncommon but occurs occasionally in athletes. Ten patients were treated with a posterior shoulder staple capsulorrhaphy. A posterior Bankhart-type-lesion was found in all cases. Eight of the 10 patients had pain relief. The range of motion was usually maintained postoperatively, but no patient returned to his former throwing status. Four patients also had anterior instability. Three patients (30%) had postoperative recurrence of their posterior instability. The two "ligamentous lax" conditions in the series both recurred. The procedure should be supplemented in the "lax" individual. Complications in 4 patients included a painful staple, postoperative adhesions, and symptomatic ectopic bone formation in two patients. Recurrent posterior shoulder dislocation is not a definite indication for operative repair; patients must be carefully selected.