Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two- to five-year follow-up.

From March 1992 to November 1998, 57 patients sustained 58 acute, initial, traumatic anterior shoulder dislocations at the United States Military Academy. Six patients selected nonoperative treatment. Three patients underwent primary open repair after diagnostic arthroscopy revealed no Bankart lesion amenable to repair with the bioabsorbable tissue tack. The remaining 48 patients with 49 anterior dislocations were treated with arthroscopic primary repair. There were 45 men and 3 women with an average age of 20 years (range, 17 to 23) and an average follow-up of 37 months (range, 24 to 60). The average Rowe score was 92 (range, 30 to 100). The average single assessment numeric evaluation patient rating was 95.5% (range, 50% to 100%). The average Short Form-36 score (physical function) for the stable shoulders was 99 (range, 95 to 100). Forty-three shoulders remained stable (88%). There were six failures (12%). Factors associated with failure included a history of bilateral shoulder instability, a 2+ sulcus sign, and poor capsulolabral tissue at the time of repair. All patients with stable shoulders returned to their preinjury levels of athletic activity. With follow-up of 5 years, we have observed significantly better results compared with nonoperative treatment in young, active adults at the United States Military Academy.

Recurrent shoulder instability after open reconstruction in athletes involved in collision and contact sports.

The purpose of this study was to evaluate the incidence of recurrent instability in a group of young athletes who underwent open shoulder stabilization with a modified Bankart repair and anterior capsulorrhaphy. Recurrent dislocation was defined as an instability episode resulting in complete dislocation requiring manual reduction. Recurrent subluxation was defined as the subjective history of the shoulder "slipping or popping out" or pain and apprehension that caused cessation of athletics for at least 1 day. Sixty-six patients (64 men and 2 women) were included in the study. A collision sport precipitated instability in 53 patients and a contact sport in 13. The average follow-up was 47 months (range, 24 to 72). The average American Shoulder and Elbow Surgeons score was 95 points (range, 71 to 100). The average Rowe score was 80 points (range, 40 to 100). Two patients had experienced recurrent dislocation after surgery (3%). Eight patients (12%) had rare (fewer than three) episodes of postsurgical subluxation. Five patients (8%) had multiple recurrent subluxations after surgery. Postsurgical recurrent instability was significantly associated with preoperative episodes of subluxation. However, all patients with rare subluxation had an excellent functional result.

A prospective study of modified Ottawa ankle rules in a military population. Interobserver agreement between physical therapists and orthopaedic surgeons.

To determine the necessity of ankle and foot radiographs, we used modified Ottawa Ankle Rules to evaluate all cadets seen with an acute ankle or midfoot injury at the United States Military Academy. This scoring system determines the need for radiographs. Each patient was independently examined and the decision rules were applied by a physical therapist and an orthopaedic surgeon. Ankle and foot radiographs were obtained for all subjects. Sensitivity, specificity, and the positive predictive value were calculated in 153 patients. There were six clinically significant ankle fractures and three midfoot fractures, for a total incidence of 5.8%. For physical therapists, the sensitivity was 100%, the specificity for ankle injuries was 40%, and the specificity for foot injuries was 79%. For orthopaedic surgeons, the sensitivity was also 100%, the specificity for ankle injuries was 46%, and the specificity for foot injuries was 79%. Interobserver agreement between the orthopaedic surgeons and physical therapists regarding the overall decision to obtain radiographs was high, with a kappa coefficient value of 0.82 for ankle injuries and 0.88 for foot injuries. There were no false-negative results. Use of the modified Ottawa Ankle Rules would have reduced the necessity for ankle and foot radiographs by 46% and 79%, respectively.

Arthroscopic management of glenohumeral instability.

There has been substantial development of techniques for performing arthroscopic surgery of the shoulder over the past 20 years. A multitude of arthroscopic techniques have been developed in an attempt to manage the unstable glenohumeral joint while decreasing surgical morbidity. The results obtained with arthroscopic stabilization have been widely variable. This review will examine the current status of arthroscopic management of glenohumeral instability. The techniques and results of arthroscopic stabilization for primary anterior glenohumeral instability, recurrent anterior instability, and multidirectional instability will be discussed. A brief discussion on thermal capsulorrhaphy is included.

Comparison of the single assessment numeric evaluation method and the Lysholm score.

The purpose of this study was to determine the correlation between the Lysholm knee score and the Single Assessment Numeric Evaluation method. Between March 1995 and December 1996, 201 followup examinations were performed on 130 college age patients who had undergone anterior cruciate ligament reconstructions. These 201 examinations were divided into five routine followup categories: 3 months, 6 months, 1 year, 2 years, and greater than 2 years. The Lysholm score from each patient's followup questionnaire was correlated with his or her Single Assessment Numeric Evaluation rating, as determined by his or her written response to the following question: On a scale from zero to 100, how would you rate your knee today (100 being normal)? All data were gathered prospectively. The mean Lysholm scores and Single Assessment Numeric Evaluation ratings ranged from 84.0 to 93.4 points and 80.0 to 93.3 points, respectively. The correlation coefficients between the Lysholm scores and the Single Assessment Numeric Evaluation ratings ranged from 0.58 to 0.87 points. The results of this study indicate that Single Assessment Numeric Evaluation ratings correlate well with measured Lysholm scores in patients with anterior cruciate ligament reconstruction. The Single Assessment Numeric Evaluation provides clinicians with an alternative mechanism to gather outcomes data with little demand on time and resources.

Nonabsorbable versus absorbable suture anchors for open Bankart repair. A prospective, randomized comparison.

Suture anchors facilitate the surgical repair of capsuloligamentous structures to bone. Bioabsorbable suture anchors, which obviate potential pitfalls in the periarticular use of permanent implants, have recently become available. We randomly assigned 40 patients to undergo modified Bankart shoulder repairs with either nonabsorbable or absorbable suture anchors. The patients had a history of recurrent traumatic anterior instability that had not improved with nonoperative management. The average patient age was 22 years (range, 17 to 46), and the average preoperative Rowe score was 47 points in the nonabsorbable anchor group and 47 points in the absorbable anchor group. Average postoperative Rowe scores were 96 and 93 points, respectively. There was one failed result in the nonabsorbable anchor group and two in the absorbable anchor group. No statistically significant subjective or objective differences were found at an average of 25 months postoperatively. Our results reveal that, in this application, bioabsorbable suture anchors are a viable option for the repair of soft tissue to bone.

Anterior shoulder instability in sport: current management recommendations.

In the young athlete, anterior shoulder dislocations are common injuries that usually result in recurrent instability, and often require surgical treatment. Non-operative treatment remains the initial recommended course for most conditions. Operative treatment has advanced to more anatomical repairs, both open and arthroscopic. The purpose of this paper is to review the evaluation and treatment of anterior shoulder instability, to include acute dislocations, acute subluxations and recurrent instability.

Comparison of the Single Assessment Numeric Evaluation method and two shoulder rating scales. Outcomes measures after shoulder surgery.

The purpose of this study was to determine the correlation between the Single Assessment Numeric Evaluation method and the Rowe and American Shoulder and Elbow Surgeons scores. Between April 1993 and December 1996, 209 follow-up examinations were performed on 163 United States Military Academy cadets after shoulder surgery. These 209 examinations were divided into five follow-up categories: 3 months, 6 months, 1 year, 2 years, and greater than 2 years. The Rowe and American Shoulder and Elbow Surgeons scores from each subject's follow-up questionnaire were correlated with his or her Single Assessment Numeric Evaluation rating, which is determined by the subject's written response to the following question: "How would you rate your shoulder today as a percentage of normal (0% to 100% scale with 100% being normal)?" Correlation coefficients between the Single Assessment Numeric Evaluation and the two scores were 0.51 to 0.79 for the Rowe score and 0.46 to 0.69 for the American Shoulder Elbow Surgeons score. The results of this study indicate that the Single Assessment Numeric Evaluation correlates well with these two scores after shoulder surgery. This study suggests that this new evaluation method provides clinicians with a mechanism to gather outcomes data with little demand on their time and resources.

Persistent disability associated with ankle sprains: a prospective examination of an athletic population.

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. At the United States Military Academy, all cadets presenting with ankle injuries during a 2-month period were included in this prospective observational study. The initial evaluation included an extensive questionnaire, physical examination, and radiographs. Ankle sprain treatment included a supervised rehabilitation program. Subjects were reevaluated at 6 weeks and 6 months with subjective assessment, physical examination, and functional testing. The mean age for all subjects was 20 years (range, 17-24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.

Arthroscopic treatment of soft-tissue impingement of the ankle in athletes.

Sixty ankle arthroscopies were performed on patients with chronic soft-tissue impingement of the ankle after an ankle sprain between January 1989 and January 1994. Preoperative examination findings featured tenderness localized to the anterolateral aspect of the ankle, no instability, and, with the exception of 2 patients, normal radiographs. A preoperative bone scan was performed on 34 patients and was positive in each case but was not specific. Arthroscopy was performed an average of 23 months after injury. Results were determined by using a new ankle rating score. Hypertrophic synovium, synovitis, or fibrous adhesions were arthroscopically visualized and resected in all cases. The average follow-up was 27 months (range, 6 to 64 months). Thirty-one patients underwent complete evaluation and 29 were evaluated over the telephone. There were 51 excellent, 7 good, 1 fair, and 1 poor results. The diagnosis of chronic soft-tissue impingement of the ankle can be made from an appropriate history, thorough physical examination, and plain radiographs. Ankle arthroscopy with resection of impinging hypertrophic synovium or fibrous bands occurring after an ankle sprain was effective in alleviating pain in athletes.

Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations.

This prospective observational study was performed on young patients, less than 24 years old, with first-time, traumatic anterior shoulder dislocations. These patients were offered either arthroscopic or nonoperative treatment. Fifty-three patients chose nonoperative treatment. Sixty-three patients elected to have arthroscopic procedures. The average patient age was 19.6 years. There were 59 men and 4 women. All procedures were performed within 10 days of dislocation. All 63 patients had hemarthrosis. Sixty-one of 63 (97%) patients treated surgically had complete detachment of the capsuloligamentous complex from the glenoid rim and neck (Perthes-Bankart lesion), with no gross evidence of intracapsular injury. Of the other two patients, one had an avulsion of the inferior glenohumeral ligament from the neck of the humerus, and one had an interstitial capsular tear adjacent to the intact glenoid labrum. Fifty-seven patients had Hill-Sachs lesions; none were large. There were six superior labral anterior posterior lesions, two with detachment of the biceps tendon. There were no rotator cuff tears. Of the 53 nonoperatively treated patients, 48 (90%) have developed recurrent instability. In this population, the capsulolabral avulsion appeared to be the primary gross pathologic lesion after a first-time dislocation. These findings, associated with the 90% nonoperative recurrence rate, suggest a strong association between recurrent instability and the Perthes-Bankart lesion in this population.

End range eccentric antagonist/concentric agonist strength ratios: a new perspective in shoulder strength assessment.

The dynamic muscle stabilizers of the shoulder are critical to high performance in the overhead athlete. Previous evaluations of shoulder strength have focused on the concentric strength of the rotator cuff. Functionally, the rotator cuff muscles interact in an eccentric/concentric fashion. This is the first study to evaluate the end range eccentric antagonist/concentric agonist ratios of the shoulder rotators. Seventy-five asymptomatic college-level males were tested through a range of 20 degrees of lateral rotation to 90 degrees of medial rotation using the Kin-Com computer-assisted, hydraulic-resisted, isokinetic dynamometer at a speed of 90 degrees/sec. The end range (60-90 degrees) ratios for the medial rotators functioning eccentrically and lateral rotators functioning concentrically were 2.39:1 and 2.15:1 for the dominant and nondominant shoulders, respectively. End range (10 degrees of lateral rotation-20 degrees of medial rotation) ratios for lateral rotators functioning eccentrically and medial rotators functioning concentrically were 1.08:1 and 1.05:1 for the dominant and nondominant shoulders, respectively. The application of this functional assessment of strength testing results may provide important information in the evaluation of the injured shoulder in the overhead athlete, for prescreening, and to gauge return to sports after injury or surgery.

Interscalene anesthesia for shoulder arthroscopy in a community-sized military hospital.

The first 100 consecutive shoulder arthroscopic procedures performed under interscalene anesthesia at a small community-sized military hospital are the basis of this report. This method of anesthesia was compared with 100 shoulder arthroscopies performed in a previous 2-year time period under general anesthesia. A variety of arthroscopic and subsequent open reconstructive procedures about the shoulder were performed using both techniques. Using the interscalene method, 87 regional blocks were entirely successful. Thirteen patients required conversion to general anesthesia for adequate pain control; however, 4 of these had a complete block in the recovery room and required no postoperative narcotics. Seven patients required supplementation with local anesthetic when an open procedure became necessary. There were no major complications. Minor complications included 5 patients with transient Horner's syndrome, 4 patients who experienced anxiety, which was controlled with sedation, and 3 with nausea or pruritus. Interscalene anesthesia provided excellent intraoperative and postoperative analgesia with low morbidity. On a subsequent questionnaire, all patients with a successful block reported that they were extremely satisfied with their experience. Ten patients who had previous shoulder surgery under general anesthesia preferred the interscalene method. In summary, interscalene anesthesia proved to be an excellent method of anesthesia for shoulder arthroscopy. The technique is reproducible within the resources available in most community-level hospitals.

The effect of tourniquet use in anterior cruciate ligament reconstruction. A prospective, randomized study.

To evaluate the effect of tourniquet use during anterior cruciate ligament reconstruction, 40 consecutive patients were randomized into two groups: Group I (tourniquet) and Group II (no tourniquet). Preoperative evaluation included electromyography, measurement of thigh and calf girth, and determination of serum creatinine phosphokinase levels. Initial postoperative evaluations included serial creatinine phosphokinase determinations. At 1 and 6 months postoperatively, the electromyographic examination was repeated and thigh and calf girth measurements were obtained. At 6 months and 1 year after surgery, the following evaluations were made: thigh and calf girth, KT-1000 arthrometric testing, isokinetic testing of quadriceps and hamstring muscles, single-legged hop test for time, single-legged hop test for distance, and the Lysholm knee score. In Group I, the tourniquet was inflated for an average of 87 minutes, with an average pressure of 269 mm Hg. At 1 month postoperatively, 6 of 20 patients in Group I had positive electromyographic recordings (compared with 2 of 20 in Group II, P = 0.08). At 1 month, thigh girths measured 10 cm proximal to the medial joint line suggested more atrophy in the tourniquet group (P = 0.07). At 6 months, all electromyographic recordings had returned to normal. At 6 months and 1 year postoperatively, girth measurements, isokinetic strength testing, functional testing, KT-1000 arthrometer evaluation, and the Lysholm knee scores were similar for both groups.

Single versus two-incision arthroscopic anterior cruciate ligament reconstruction.

The purpose of this study was to compare single (endoscopic) versus two-incision arthroscopic anterior cruciate ligament reconstruction using bone-patellar tendon-bone in a population of young athletes. All patients followed a similar postoperative rehabilitation program. The Lysholm knee score, the International Knee Documentation Committee Score, KT-1000 arthrometric measurements, Lachman tests, pivot shift tests, isokinetic and functional testing, and perioperative complications were used to compare the two techniques. Anteroposterior and lateral radiographs were also evaluated and compared. Group I comprised 51 patients who underwent two-incision arthroscopic ACL reconstruction. The average age was 19.8 years, with a range of 18 to 22. The average follow-up in this group was 31 months (range, 24 to 43 months). Group II, the endoscopic group, consisted of 31 patients with an average age of 19.4 years (range, 18 to 22). The average follow-up was 25 months (range, 24 to 31 months). There were no significant differences between the two groups using subjective, objective, and functional criteria. There did appear to be a trend toward a residual pivot glide in the endoscopic group, but this did not achieve statistical significance. Radiographic analysis demonstrated an increased incidence of screw divergence in the endoscopic group. Intraoperative complications were more common with the endoscopic method.

Endoscopic anterior cruciate ligament reconstruction: complication of graft rupture and a method of salvage.

The following case report highlights the complications of endoscopic anterior cruciate ligament reconstruction. One such complication involving autograft rupture in placement of the femoral screw is described. A method of salvage using the existing autograft is elucidated by converting to a two-incision technique. Furthermore, the case report demonstrates a soft-tissue suturing technique described by Krackow that enabled salvaging the previously harvested autograft and securing over a ligament button. Second-look arthroscopy at 8 months after the combined medial meniscus repair and ACL reconstruction confirmed healing. At follow-up 3 years after surgery, the result was excellent using both the Lysholm and IKDC scoring system.

Arthroscopic stabilization of acute initial anterior shoulder dislocation: the West Point experience.

Arthroscopic stabilization for acute initial shoulder dislocation has been the subject of thorough investigation at West Point over the past decade in an attempt to improve on the natural history of shoulder instability in our young athletic population. From January 1986 to December 1995, 127 patients were treated for acute initial shoulder dislocation at the United States Military Academy. Of the 55 patients treated nonoperatively, 47 (85%) have had recurrence of instability. Seventy-two patients were treated operatively during three separate phases in the evolution of arthroscopic management at our institution. The initial phase (1986 to 1988) of operative treatment included either arthroscopic abrasion or staple repair. The low recurrence rate (2 of 9) was promising. In the operative technique for the second phase (1988 to 1991) transglenoid sutures were used. Of the 21 patients treated in this manner, 18 (86%) had no recurrent instability at last follow-up (average, 32 months). In the third phase (1991 to 1993), patients were treated with a bioabsorbable tack and interscalene anesthesia, and in the sitting position. Thus far, 39 of the latest 42 cadetathletes with acute initial anterior shoulder dislocations have had stabilization with this bioabsorbable cannulated fixation device. The average age was 19.5 years (range, 17 to 23 years). Follow-up averaged 22 months. There were no perioperative complications. Of these 39 patients, 35 (90%) have a stable shoulder and have returned to preinjury performance status. One of 2 patients with recurrent subluxation and 1 of 2 patients with a traumatic redislocation required an open Bankart repair. In young athletes known to have high recurrence rates with nonoperative treatment, acute arthroscopic stabilization appears to be an effective minimally invasive treatment option that favorably alters the natural history of shoulder instability.