Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations.

We describe the biceps load test for evaluating the integrity of the superior glenoid labrum in shoulders with recurrent anterior dislocations. With the shoulder in an abducted, externally rotated position and the forearm supinated, active flexion of the elbow against resistance relieves the discomfort of a standard apprehension test for anterior shoulder instability. A group of 75 patients with proven unilateral anterior shoulder dislocations were prospectively examined in a double-blind fashion with arthroscopic examination and the biceps load test. Sixty-three patients had a negative test and 62 of these had an intact biceps tendon-superior labrum complex; the remaining patient had a type II superior labral anterior and posterior lesion. Twelve patients had positive tests, and 10 had superior labral lesions; the other 2 patients had intact superior labra. Therefore, the biceps load test revealed a sensitivity of 90.9%, a specificity of 96.9%, a positive predictive value of 83%, a negative predictive value of 98%, and a kappa coefficient of 0.846.

Stress fractures of the ribs in golfers.

During a collaborative review at three institutions, we documented 19 cases of stress fractures of the ribs in golfers. There were 13 men and 6 women with an average age of 39 years (range, 29 to 51). The 4th to 6th ribs were the most commonly injured. All fractures occurred along the posterolateral aspect of the ribs, and nine patients had fractures in more than one rib. Sixteen golfers sustained injury on the leading arm side of the trunk. Eighteen golfers were beginners, and the one experienced golfer had dramatically increased his practice time on the driving range before injury. Plain radiographs were usually diagnostic. However, bone scintigraphy was necessary to reach a diagnosis in three cases. A delay in diagnosis of 6 to 8 months occurred in two cases that were originally misdiagnosed as back strains. Stress fractures of the ribs in golfers may be more common than previously realized and may be incorrectly diagnosed as recalcitrant back strains. Based on the findings of other studies, we think fatigue of the serratus anterior is the mechanism of injury. We recommend strengthening the serratus anterior as rehabilitation after this injury and in a general conditioning program for golfers.

Arthroscopic treatment for impingement of the anterolateral soft tissues of the ankle.

We treated 52 patients with impingement of the anterolateral soft tissues of the ankle by arthroscopic debridement. All had a history of single or multiple inversion injuries, without instability. One half had negative stress radiographs (stable group), while the others were positive (unstable group). Their mean age was 31 years and there were 35 men and 17 women. The results were assessed at a mean follow-up of 30 months. Three patients (6%) had a fair result, while 49 (94%) had an excellent or good outcome. No difference was found in the final results between the two groups (p > 0.05). We conclude that anterolateral impingement of the ankle should be considered in a patient with chronic anterolateral pain after an injury, regardless of the stability of the ankle.

Percutaneous release of trigger digits.

We describe a safe and easy percutaneous technique for release of trigger finger using a specially designed knife. The A1 pulley is sectioned by a blade which has a hooked end. We released, percutaneously, 185 trigger fingers, including 62 which were locked using this technique. Satisfactory results were achieved in 173 (93.5%). There were no significant complications. We recommend this as a safe and effective outpatient procedure for those patients who have not responded successfully to conservative treatment, have longstanding symptoms or severe triggering.

Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture.

PURPOSE: The purpose of this study is to describe arthroscopic findings and the results of arthroscopic treatment of patients with chronic shoulder pain caused by a minimally displaced fracture of the greater tuberosity. TYPE OF STUDY: This is a retrospective case series in a consecutive sample of 23 patients with a minimally displaced or nondisplaced fracture of the greater tuberosity who underwent outcome analysis after arthroscopic treatment. MATERIALS AND METHODS: Twenty-three patients with chronic shoulder pain beyond 6 months after fracture of the greater tuberosity underwent arthroscopic treatment and were retrospectively assessed after an average of 29 months (range, 22 to 40 months). There were 18 men and 5 women with the average age of 39 years (range, 24 to 61 years). Fourteen fractures were isolated and 9 were related to acute anterior instability episode. The average displacement of the fracture was 2.3 mm (range, 0 to 4 mm) as shown on anteroposterior view plain radiographs. RESULTS: At the time of arthroscopy, all patients had partial-thickness rotator cuff tears on the articular surface. The cuff tears were located on the tuberosity fracture area and were an Ellman grade I to II in depth. After arthroscopic debridement or repair of the tear, depending on the condition of the tear itself, as well as subacromial decompression, the UCLA score results were good to excellent in 20 and fair in 3 patients. Nineteen of the patients had returned to the previous level of activities. However, the patients engaged in overhead sports activity had a lower level of return to activity (P =.034). CONCLUSIONS: A partial-thickness rotator cuff tear on the articular surface should be considered in patients with chronic shoulder pain after a minimally displaced fracture of the greater tuberosity. Arthroscopic debridement or repair is an appropriate procedure.

Significance of the internal locking mechanism for loop security enhancement in the arthroscopic knot.

PURPOSE: Secure tissue fixation of an arthroscopic knot depends on the security of the initial loop and additional locking half-hitches. The purpose of this report is to evaluate the loop and knot security relative to the internal locking mechanism of arthroscopic slip knot. TYPE OF STUDY: This is an experimental study designed for knot and loop security on a material testing system. The measurements were carried out in a blinded fashion in which the tester was not aware of the type of knot being tested. METHODS: Five configurations of arthroscopic knots (overhand throw, Duncan loop, Revo knot, Tennessee slider, and SMC knot) were created around a 5-mm diameter metal bar using a No. 2 braided suture. For each knot configuration, 10 knots were tested for displacement at cyclic loading, load to clinical failure (3-mm displacement), ultimate failure load, and mode of failure on the servo-hydraulic material testing system (MTS 858 MiniBionix test system; MTS, Minneapolis, MN). A 1-way analysis of variance was used to determine the statistical difference in displacement at cyclic loading, load to clinical failure, and ultimate failure load between each knot configuration. RESULTS: In the cyclic loading test, the average displacement of all knots was clinically insignificant, with the average being less than 0.24 mm. The overhand throw had the worst characteristic in the load to failure test. The other 4 knots had an optimal load to failure. The SMC knot, which has an internal locking mechanism, had good loop and knot security in the load to clinical failure and ultimate failure load (P <.05). The SMC and the Revo knots failed by knot breakage (material failure) whereas the other knots failed by knot slippage (loop failure). CONCLUSIONS: The internal locking mechanism flips the post strand to convert the loop strand into a new post strand while rerouting the original post strand around a new post. An arthroscopic knot with an internal locking mechanism can enhance loop security.

Electromyographic activity of the biceps brachii muscle in shoulders with anterior instability.

PURPOSE: The purpose of this study was to evaluate the activity of the biceps muscle in the vulnerable abduction and external rotation position of the shoulder in patients with anterior instability. TYPE OF STUDY: This experimental study included a prospective analysis of the electromyographic (EMG) data on a group of patients with traumatic unilateral anterior instability of the shoulder. The EMG data of the unstable shoulders was compared with those of the opposite shoulders as control. The optimal sample size for the case-control study was calculated using an nQuery Advisor program (nQuery Advisor 3.0, Statistical Solutions, Cork, Ireland). METHODS: The EMG analyses were conducted in 76 shoulders in 38 patients who had a traumatic anterior instability in 1 shoulder. The EMG records were obtained at different positions of the shoulder, which included 0 degrees, 45 degrees, 90 degrees, and 120 degrees of shoulder abduction. In each angle of shoulder abduction, the arms were placed in an external rotation as tolerated by the anterior apprehension. The paired-sample t test was used to compare the difference of the root mean square (RMS) voltages between the stable and unstable shoulders in each degree of arm position. RESULTS: The RMS voltage of the biceps muscle was significantly greater in the unstable shoulder than the opposite stable shoulder in all positions of the arm (P =.00). The RMS voltage of the biceps was maximal at 90 degrees and 120 degrees of external rotation in the unstable shoulder (P <.05). The RMS voltage of the supraspinatus muscle revealed no differences in any of the test conditions (P =.904,.506,.119, and.781 in 0 degrees, 45 degrees, 90 degrees, and 120 degrees, respectively). CONCLUSIONS: In the vulnerable abduction and externally rotated position, the biceps muscle plays an active compensatory role in the unstable shoulder but not in the stable shoulder.

Biceps load test II: A clinical test for SLAP lesions of the shoulder.

PURPOSE: The purpose of this report is to describe the biceps load test II for evaluating the superior labral anterior and posterior (SLAP) lesions. TYPE OF STUDY: This is a double-blind study in consecutive data, which includes diagnostic accuracy of a test using sensitivity, specificity, and interexaminer reliability. METHODS: In the supine position, the arm is elevated to 120 degrees and externally rotated to its maximal point, with the elbow in the 90 degrees flexion and the forearm in the supinated position. The patient is asked to flex the elbow while resisting the elbow flexion by the examiner. The test is considered positive if the patient complains of pain during the resisted elbow flexion. The test is negative if pain is not elicited or if the pre-existing pain during the elevation and external rotation of the arm is unchanged or diminished by the resisted elbow flexion. A prospective study was performed in 127 patients to evaluate the diagnostic accuracy for the biceps load test II. Two independent examiners were assigned to perform the new diagnostic test. The results of the tests were confirmed during the arthroscopic examination. RESULTS: A positive test result in 38 subjects correlated with a SLAP lesion in 35 patients and an intact biceps-superior labrum in 3 patients. A negative test result in 89 patients correlated with an intact superior labrum complex in 85 patients, whereas 4 patients with a negative test result had a type II SLAP lesion. The biceps load test II had a sensitivity of 89.7%, a specificity of 96.9%, a positive-predictive value of 92.1%, a negative-predictive value of 95.5%, and a kappa coefficient of 0.815. The abduction and external rotation of the shoulder during the test changes the relative direction of the biceps fiber in a position of oblique angle to the posterosuperior labrum. The resisted contraction of the biceps increases the pain generated on the superior labrum that is already peeled off the glenoid margin in the abducted and externally rotated position. CONCLUSIONS: The biceps load test II is an effective diagnostic test for SLAP lesions.

A1 pulley release of locked trigger digit by percutaneous technique.

We performed 118 percutaneous releases of the locked trigger digits in an office setting using a specially designed knife. Thirty-five digits were locked in flexion, 79 digits in extension and the remaining four were fixed in a semiflexed position. Successful percutaneous release was achieved for 107 digits (91%), with the remaining 11 digits requiring an open surgical procedure. Although there were no persistent triggering in 98 digits with a follow-up of at least 6 months, painful stiffness at the interphalangeal joints remained in ten digits despite of physical therapy. No neurovascular injury occurred. We suggest that a locked trigger digit can be successfully released with the percutaneous technique.

A clinical study of stress fractures in sports activities.

One hundred thirty-one patients with 169 stress fractures were treated between January 1984 and January 1990. The highest incidence was in teenage girls (25.5%), and the predominant sites were tibia (31.5%) and femur (12.5%). The mean interval between the start of hard training and the onset of symptoms was 2.7 months and the mean amount of increased activities was 93.7%. Volleyball (24.3%) and running (17.3%) had the majority of incidents, and 95 (72.5%) patients were professional athletes. Radionuclide bone scans were needed in 61 (46.6%) patients and 16 (12.2%) showed multiple lesions. Asymptomatic stress fractures were found in 12 (9.2%) patients, and only five showed recurrence at the other sites. Eleven (6.5%) cases were treated operatively, and involved the tarsal navicular (2.9%) and femur (2.4%).

The SMC knot--a new slip knot with locking mechanism.

A new slip knot for arthroscopic surgery, the SMC knot, is described. By pulling the post strand, a self-locking loop is created. By tensioning the loop strand, the self-locking loop creates a snug knot without sliding backward. The SMC knot is simple and has a low profile. With a nonabsorbable suture, it provides great knot security.

The HAKI technique of femoral interference screw insertion.

We describe a simple and reliable technique, the HAKI technique, of femoral interference screw fixation that can reduce surgical complications. In 83 ordinary endoscopic anterior cruciate ligament (ACL) reconstructions and 110 ACL reconstructions with our new technique, surgical complications related to the femoral interference screw fixation were evaluated. With our new technique, only one complication occurred while overall complications of 15.7% occurred in the ordinary group. Compared with the ordinary technique group, which had an average of 12.0 degrees screw divergence on anteroposterior radiographs and 13.5 degrees on lateral radiographs, our new technique had a significantly lower incidence of femoral screw divergence, with 8.0 degrees and 8.3 degrees on the anteroposterior and lateral views, respectively. This new technique could reduce a significant portion of complications that occur during endoscopic (single incision) bone-patellar tendon-bone ACL reconstruction.

Tram track lesion of the talar dome.

A distinctive lesion in the articular cartilage of the talar dome in anterior bony impingement syndrome of the ankle joint is reported. During arthroscopic treatment of anterior bony impingement syndrome of the ankle, we found six distinctive articular cartilage lesions in the talar dome. The cartilage lesions were full-thickness defects (grade IV), located in the anterior half of the medial aspect of the talar dome and were longitudinal with variable widths resembling a tram track; thus, "tram track lesion." All six patients were professional or collegiate soccer players and had large osteophytes in the anteromedial ridge of the tibial articular margin. Instability test results were negative. All patients had the typical tenderness in the anteromedial comer of the ankle. Overall, good and excellent results were achieved in five patients at a mean follow-up of 27 months after arthroscopic excision of osteophytes and drilling using K-wires.

A clinical study of the natural remodeling of burst fractures of the lumbar spine.

Surgical decompression and fixation are considered by many to be the preferred treatment for burst fractures of the lumbar spine, regardless of neurologic deficit. For 6 patients with burst fracture of the lumbar spine but without neurologic deficit, computed tomography scans revealed >50% encroachment of the spinal canal. All 6 patients were treated conservatively, and during the followup period (range, 6-49 months), the narrowing of the spinal canal decreased progressively because of resorption of the fragments and natural remodeling. The presence of a neurologic deficit should be the primary indication for surgery in patients with a burst fracture of the lumbar spine.

Anterior cruciate ligament reconstruction in the young patient without violation of the epiphyseal plate.

A technique of arthroscopic anterior cruciate ligament reconstruction that does not disturb the epiphyseal plate in the young patient with open physis is presented. A cryopreserved bone-Achilles tendon allograft was incorporated by an interference screw fixation to the bone plug in the tibia and an over-the-top positioning of the tendon on the femoral side. For this procedure, the minimal patient age that the thickness of the epiphysis can accept an interference screw greater than 15 mm in length is 8 years. An intra-articular reconstruction of anterior cruciate ligament with the cryopreserved Achilles allograft using our technique is safe and recommendable for young patients with open physis.