Thrombosis of the brachial artery after closed dislocation of the elbow.

The brachial artery is rarely injured after closed dislocation of the elbow. We describe an unusual variation of this injury, namely, a delayed thrombosis of the brachial artery after a closed dislocation sustained during a low-energy fall. This has not previously been described in the English literature, but may be more common than this suggests. We stress the importance of a thorough neurovascular examination and vigilance in regard to this potentially disastrous complication.

Total elbow arthroplasty with the Coonrad/Coonrad-Morrey prosthesis. A 10- to 31-year survival analysis.

There have been few reports in the literature of total elbow arthroplasty extending beyond 10 to 15 years. We reviewed 40 patients (41 elbows) with a mean age of 56 years (19 to 83) who had undergone a Coonrad/Coonrad-Morrey elbow arthroplasty by one surgeon for various diagnoses between 1974 and 1994. Surgical selection excluded patients with previous elbow infection or who refused to accept a sedentary level of elbow activity postoperatively. Objective data were collected from charts, radiographs, clinical photographs and supplemented by the referring orthopaedic surgeons' records and radiographs if health or distance prevented a patient from returning for final review. Subjective outcome was defined by patient satisfaction. Of the 41 elbows, 21 were functional between 10 and 14 years after operation, ten between 15 and 19 years and ten between 20 and 31 years. There were 14 complications and 13 revisions, but no cases of acute infection, or permanent removal of any implant.

Patient-controlled lidocaine analgesia for acromioplasty surgery.

Twenty-four consecutive patients undergoing shoulder acromioplasty were given postoperative analgesia with a new method in which a patient-controlled continuous infusion of lidocaine infiltrated the subacromial space. Seventeen of the acromioplasties were done with arthroscopy, whereas 7 were performed with an open procedure. A 2% solution of lidocaine without epinephrine was used for both a continuous dose of 2 cc/h and patient-controlled interval doses of 1 cc administered at 15-minute intervals. The catheter was left in place for 72 hours. We prospectively studied complications, the patient's subjective pain level, the amount of supplementary pain medication used, and serum levels of lidocaine. In addition, we evaluated a control group of 24 patients undergoing acromioplasty by the same surgeon without the use of this method of pain control. No wound complications occurred. No adverse reactions to lidocaine or overdose of lidocaine occurred. Blood levels of lidocaine averaged 0.3 microgram/mL in the 12 patients studied. Subjective pain levels and the amount of supplementary pain medication used were both lower in the group receiving patient-controlled lidocaine analgesia at statistically significant levels (P = .168 measuring subjective pain level, and P = .0212 measuring supplementary pain medication use). Patient-controlled lidocaine analgesia in the subacromial space appears to be a safe method for achieving high levels of pain control in patients undergoing an acromioplasty.

The pain control infusion pump for postoperative pain control in shoulder surgery.

PURPOSE: This study was initiated to evaluate the effect of a pain control infusion catheter in managing postoperative pain. TYPE OF STUDY: In a prospective, randomized trial, 62 consecutive patients undergoing arthroscopic subacromial decompression had an indwelling pain control infusion catheter placed at the operative site. MATERIALS AND METHODS: Thirty-one patients received 0.25% bupivacaine and 31 patients received saline infusions, each at a constant rate of 2 mL per hour. Patients evaluated their pain by visual analog scale, and also tabulated the amount of narcotic and nonnarcotic medication used each day in the first week of surgery. RESULTS: There was a statistically significant difference in pain in all parameters tested in the bupivacaine group as compared with the saline control group (P <.05). CONCLUSIONS: The bupivacaine pain control infusion pump is an effective means of decreasing postoperative pain.

E. Amory Codman, surgeon of the 1990s.

Ernest Amory Codman is known to orthopaedists primarily for his work in shoulder surgery. But his contributions reached many other fields of medicine, including pathology, radiology, anesthesiology, and most surgical subspecialties. Perhaps his most important work was that on the "end result idea," an early approach to outcome studies that anticipated much of the current health-care climate. This article examines his life and explains his contributions to medicine and surgery and their pertinence to current practice.

Reliability and reproducibility of radiographic interpretation of proximal humeral fracture pathoanatomy.

Recent studies have demonstrated inconsistencies in the use of certain images for classifying proximal humerus fractures. Our purpose was to determine whether three-dimensional computed tomography or the level of expertise of the observers would improve the reliability and reproducibility of identifying specific anatomic fragments in proximal humerus fractures. Two groups of observers, nonexperts and experts in shoulder surgery, were asked to review the radiographs and three-dimensional computed tomography scans of 12 patients with proximal humerus fractures. Observers were asked to identify displaced fracture fragments, dislocation, and articular surface fractures. Both groups of observers displayed suboptimal reliability for the identification of displaced fracture fragments. The addition of three-dimensional computed tomography scans did not improve the reliability or reproducibility. Poor agreement for the purpose of classification seems to occur at the most fundamental level, the pathoanatomic description of the fracture. Inconsistencies may have been due to imprecise identification and measurement of individual fracture fragments, differing interpretations of the pathoanatomy, or both.

Suprascapular neuropathy after distal clavicle excision.

Two cases of suprascapular neuropathy after excision of the distal clavicle are reported. Both patients were treated successfully with neurolysis of the suprascapular nerve starting at the upper trunk of the brachial plexus. Anatomic dissections revealed that the suprascapular nerve is quite close (<1.4 cm) to the posterior aspect of the distal clavicle, within 2 to 3 cm of the acromioclavicular joint. To avoid the complication of suprascapular neuropathy that could be associated with this close relationship, it is recommended that no more than 1 cm of the distal clavicle be removed posteriorly. It is also recommended that minimal periosteal elevation should be performed on the posteroinferior border of the distal clavicle.

Use of vertebral levels to measure presumed internal rotation at the shoulder: a radiographic analysis.

Internal rotation of the shoulder is frequently measured by noting the maximal vertebral level reached by the patient's thumb, but it is not at all certain that this maneuver is strictly measuring internal rotation. We analyzed this maneuver with computed tomographic scans of the shoulder in differing positions. We also analyzed extension of the glenohumeral joint and scapulothoracic articulation with scapular lateral radiographs. Finally, we used posteroanterior radiographs to analyze elbow flexion at the limits of internal rotation behind the back. We found that maximal internal rotation behind the back occurs in approximately a 2 : 1 ratio between the glenohumeral joint and the scapulothoracic articulation. However, the scapulothoracic articulation was more significant in placing the arm behind the back, whereas the glenohumeral joint performed most of the internal rotation in front of the body. The scapulothoracic articulation assists in this motion by both extension and internal rotation of the scapula on the thorax. The limits of internal rotation behind the back are reached with a significant contribution from elbow flexion. We conclude that measuring shoulder internal rotation by the maximal vertebral level reached by the patient's thumb greatly oversimplifies the concept of internal rotation and that limitations in this motion may not be strictly due to a loss of internal rotation at the glenohumeral joint.

Total joint replacement and golf.

Definitive characterization of the effects of golf on a total joint replacement remains elusive. However, from our study of active golfers and solicitation of the opinions of orthopedists who specialize in joint replacements, and from a careful review of the literature regarding exercise and total joint replacement, it appears possible for patients to remain active golfers with no significant increase in either symptoms or rates of revision of implants following total hip, knee, or shoulder replacement.

Reliability of radiographic assessment of acromial morphology.

The most widely used radiographic classification system for acromial morphology identifies three distinct acromial shapes: type I (flat), type II (curved), and type III (hooked). The purpose of this study was to measure the interobserver and intraobserver reliability of determinations of acromial morphology as defined by this system. Between 1990 and 1992, one hundred twenty-six supraspinatus outlet radiographs were obtained from 126 patients by technicians from Triangle Orthopaedic Associates in Durham, N.C. Six fellowship-trained shoulder surgeons independently reviewed each radiograph and classified it as type I, II, or III on the basis of established guidelines. Two surgeons classified each film a second time in random order. Analysis of variance was performed to obtain coefficients for interobserver and intraobserver reliability. Consensus ratings were then used to classify the 126 radiographs into consensus type I, consensus type II, or consensus type III groups. Percentages of type I, II, and III individual ratings within each consensus group were determined. The intraobserver reliability coefficient was 0.888, interpreted as good to excellent reliability. The interobserver reliability coefficient was 0.516, interpreted as poor to fair reliability. Of the 126 radiographs, 26 (20.6%) were rated as consensus type I, 76 (60.3%) were rated as consensus type II, and 24 (19.1%) were rated as consensus type III. The reliability of observer ratings was lowest when delineation between acromial types II and III was required. The low interobserver reliability makes comparisons of studies by different authors difficult to interpret and obscures the true incidence of acromial morphologic types. It also questions reported correlations between acromial type and shoulder pathologic conditions. It is concluded that a system that incorporates more objective classification criteria and acknowledges the continuous nature of acromial morphologic types may improve interobserver reliability and validate the system's use in making clinical and surgical judgments.

Multidirectional instability: current concepts.

Multidirectional instability (MDI) of the shoulder is a complex problem that is not yet well understood. Instability in several directions is termed MDI, but the precise definition, classification, cause, and optimal method of treatment remains elusive. The cause appears to be multifactorial, with biochemical and biomechanical abnormalities present in shoulders with MDI. The biomechanical factors responsible for preventing MDI include bony architecture, concavity-compression from the deepening of the glenoid by the labrum, stability from the ligaments, primarily the inferior glenohumeral ligament complex and the superior capsular structures, and muscular control by use of force couples, especially stabilization of the scapula. Current recommended treatment is initially nonoperative, with aggressive physical therapy aimed at strengthening the rotator cuff and the scapular stabilizers. Patients who fail to respond to a nonoperative regimen often improve with surgical stabilization, which is usually an inferior capsular shift or a variant of that procedure. After this surgery immobilization of the operated shoulder for 6 to 8 weeks is recommended by most authors.

Acromioclavicular joint injury in competitive golfers.

We reviewed a series of professional and competitive low-handicap golfers with shoulder pain. All but one player (34/35) had pain in the left shoulder. A high incidence of problems (53%) related to the acromioclavicular joint was noted in these golfers with left shoulder pain. With proper treatment all but one (17/18 [94%]) of the golfers with acromioclavicular joint problems was able to return to competitive golf. By studying the mechanics of the golf swing, a possible mechanism for this high incidence of acromioclavicular joint problems is given.

Mycoplasma hominis septic arthritis: two case reports and review.

Mycoplasma hominis is normally a commensal of humans. When the organism is pathogenic, it primarily causes disease in the genitourinary tract. Septic arthritis caused by M. hominis is a rare condition that occurs chiefly in the postpartum period, in immunosuppressed hosts, or in patients who have recently undergone urinary tract manipulation. Arthritis caused by M. hominis is clinically indistinguishable from septic arthritis caused by other bacteria. Diagnosis is often delayed because infection with this organism is not suspected or because it grows slowly, if at all, in routine culture media. Appropriate therapy often leads to a good outcome, although relapses and resistance have been reported.

Total joint replacement in active golfers.

Total joint replacement is commonly done in an older population, for whom golf is often the only form of exercise. We studied active golfers after they had had a total joint replacement. Most golfers with a successful primary total joint replacement will not have pain while playing golf, but will likely have a mild ache in the hip or knee region after playing. Patients with total knee replacement appear to have slightly more postgolf pain than patients with total hip replacement. In addition, golfers with left total knee replacements have more difficulty with pain during and after play than do golfers with right total knee replacements.

Total knee arthroplasty in active golfers.

The results of total knee arthroplasty (TKA) in patients who actively exercise have not been previously studied. Golf is a frequent form of exercise for the older population in whom TKAs are usually performed. Members of The Knee Society permit their patients with TKA to play golf, if they desire to do so. They recommend waiting approximately 18 weeks after surgery before beginning to play. Most members of The Knee Society stated that they have no preferences as to the model of knee arthroplasties in golfers, although 35.2% did state that they would use a posterior-cruciate sparing model. After TKA, active golfers in the authors' study (83) invariably experienced a significant rise in their handicap (mean +4.6 strokes) and also a decrease in the length of their drives. Most (86.7%) use a cart while playing, but still a small percentage (15.7%) will have a mild ache in the knee while playing and a larger percentage (34.9%) will have a mild ache in the knee after playing. In addition, golfers with left TKAs have more difficulty with pain during and after play (P < .01) than do golfers with right TKAs. Radiolucencies were also common in our study, occurring in 53.7% of all knees studied and 79.1% of cemented TKAs.

The medial approach to the hip revisited.

Several muscular intervals have been described to approach the hip through a medial incision. We studied in detail the original descriptions of these surgical planes and found that several of them are nearly identical. We attempt to clarify the anatomic intervals available to the surgeon in hope of eliminating ambiguity in future reporting.

Ultrasonography of the rotator cuff: Analysis of results in a community setting.

Forty-six patients underwent ultrasonogrophy evaluation of their shoulder for suspected rotator cuff tears from 1989 to 1992. All ultrasound studies were evaluated by a radiologist (HJH) who was not subspecialty-trained in shoulder ultrasonography. All patients had surgical confirmation of the status of their tendons. A statistical analysis of the accuracy of ultrasound in detecting rotator cuff tearing was performed. The sensitivity was 81%, and the specificity was 100%; there was a positive predictive value of 100% and a negative predictive value of 71%. Using strict sonographic criteria for diagnosing a rotator cuff tear, we conclude that ultrasound can detect intermediate or large rotator cuff tears with great accuracy (19 of 20 shoulders). Accuracy decreases dramatically in the presence of a small tear (six of 11 shoulders). At our hospital the cost of ultrasound examination of the shoulder is 0.19 the cost of magnetic resonance imaging of the shoulder and is 0.62 the cost of a shoulder arthrogrom. Ultrasound of the shoulder should be considered for imaging the rotator cuff because of its accuracy, low cost, and high patient satisfaction. It can be reliably performed by radiologists with state-of-the-art equipment who are interested in and have experience with the procedure.

The glenohumeral offset ratio: A radiographic study.

A systematic method of component selection for total shoulder arthroplasty is needed. The method must take into account the soft-tissue constraints of a degenerative joint and optimize joint biomechanics by placing the joint line in the best possible position. The purpose of our study was to determine radiographically the normal glenohumeral joint line position based on a ratio of distances between the joint line and fixed landmarks on the humerus and scapula. We studied modified anteroposterior radiographs of the glenohumeral joint in 86 volunteers (51 men and 35 women; ages ranging from 21 to 47 years). Two measurements were made on each radiograph: (1) the perpendicular distance from the most medial portion of the glenoid to the inferior base of the coracoid process at its attachment to the scapular blade, and (2) the perpendicular distance from the midline of the humeral shaft to the most medial point on the humeral head. The joint line position was described as the ratio of the glenoid measurement to the sum of the two measurements (i.e., the glenohumeral offset ratio). The validity and reliability of glenoid offset measurements were determined by comparing radiographic and anatomic measurements of glenoid offset in cadaveric human scapulae. Radiographs were made with rotational error to determine its effects on the measurement of humeral offset. Humeral offsets and glenoid thicknesses of five different total shoulder systems were then determined from template overlays. The mean glenohumeral offset ratio was 0.31 (range 0.18 to 0.39). We detected no significant difference in the ratio between men and women volunteers. There was close agreement between radiographie and direct (anatomic) measurements of glenoid offset in cadaveric scapulae. Values for humeral offset were not significantly affected by radiographic rotational error. The evidence indicates that a fairly constant glenohumeral offset ratio in normal shoulders can be reliably calculated from a single radiograph. In addition to the prosthesis specifications, we suggest that the glenohumeral offset ratio is a potentially useful preoperative planning tool for total shoulder arthroplasty.