Spinner RJ, Goldner RD [ Duke Univ, Durham, NC]
Snapping of the Medial Head of the Triceps and Recurrent Dislocation of the Ulnar Nerve: Anatomical and Dynamic Factors
J Bone Joint Surg Am 80 – A: 239-247, 1998
Snapping of the medial head of triceps may often go unrecognised. Failure to recognise that this lesion and concurrent dislocation of the ulnar nerve can lead to persist symptoms after an otherwise successful transposition of the ulnar nerve.
They conclude that persistant snapping after a successful transposition of the ulnar nerve can result from failure to recognise concurrent dislocation of the medial head of triceps. This snapping could be asymptomatic also. The results of non operative treatment are also good.
Ellenbecker TS, Mattalino AJ, Elam EA, et al [ Scottsdale Sports Clinic, Ariz; Clinical Diagnostic Radiology Ltd, Phoenix, Ariz; Milwaukee Brewers Baseball Club, Milwaukee, Wis]
Medial Elbow Joint Laxity in Professional Baseball Pitchers: A Bilateral Comparison Using Stress Radiography
Am J Sports Med 26: 420-424, 1998
Baseball pitching and other throwing activities place repetitive valgus stress on the elbow leading to ulnar collateral ligament injury. This study compared medial elbow laxity in the throwing and non-throwing arms of 40 professional baseball pitchers.
The clinical range of motion of the elbows and wrist and bilateral stress radiography was done and the laxity was calculated by measuring joint space width between the trochlea and the coronoid process on anteroposterior radiographs.
The dominant arm showed greater medial joint width and reduced range of movement [particularly extension] than the non dominant arm.
They conclude that professional baseball pitchers show increased medial elbow laxity in the throwing arm than the other arm. Stress radiography is a reliable test to demonstrate this.
Lee GA, Katz SD, Lazarus MD [Albert Einstein Med Ctr, Philadelphia]
Elbow Valgus Stress Radiography in an Uninjured Population
Am J Sports Med 26: 425-427, 1998
Valgus instability of the elbow is usually diagnosed clinically, though some have used gravity valgus stress radiography to aid in diagnosis. The amount of ulnahumeral gapping was measured in normal elbows by this method.
40 asymptomatic people [ 20 men and 20 women] mean age [ 27 years] were studied. Both elbows were radiographed with the elbows in extension and in 300 flexion. Medial ulnahumeral distance was measured in 3 situations. [a] No stress [b] gravity valgus stress [c] applied valgus stress.
The ulnahumeral distance increased significantly with increasing stress.
They conclude that even in normal elbows valgus stress causes significant increase in ulnahumeral distance. This test could be used for diagnosis of valgus instability in injured patients but is of no value in uninjured elbows.
Zeman C, Hunter RE, Freeman JR, et al [Orthopaedic Associates of Asper, Colo; Aspen Found for Sports Medicine, Education and Research, Colo]
Acute Skiers Thumb Repaired with a Proximal Phalanx Suture Anchor
Am J Sports Med 26: 644-650, 1998
58 patients with grade III sprains of the UCL [Ulnar Collateral Ligament] were repaired using a suture anchor for fixation of thumb to the proximal phalanx. After a year a 14 point questionnaire was administered to determine functional outcomes.
98% of the interviewed patients were satisfied with the result and had a stable repair with good range of movements and no hindrance in their activities. 17% reported mild discomfort and 7% experienced pain in the activities.
This is a good method of repair.
Mont MA, LaPorte DM, Mullick T, et al [ Johns Hopkins Univ, Baltimore, Md]
Tennis After Total Hip Arthroplasty
Am J Sports Med 27: 60-64, 1999
Many active patients wish to continue playing tennis after hip arthroplasty. Only 14% of surgeons had approved of their playing tennis. 34% recommended only doubles.
A survey was conducted on such patients. 50 men and 8 women aged 47 to 89 years were identified. The survey was meant to assess the functional abilities and degree of satisfaction in this group.
All were very satisfied with their surgeries and their increased ability to play tennis. After a mean of 8 years 3 patients needed revision surgery.
Physicians should advise caution in restarting the game of tennis after hip arthroplasty and they should be followed annually for local changes in the bones.
Clanton TO, Coupe KJ [Univ of Texas, Houston]
Hamstring Strains in Athletes : Diagnosis and Treatment
J Am Acad Orthop Surg 6: 237-248, 1998
Hamstring injuries are common, well-defined athletic injuries. Their diagnosis is discussed.
The hamstrings act during the early stance phase of gait for knee support, during the late stance phase for propulsion, and during midswing to control leg momentum. Injuries occurs at musculotendinous junction where forces are concentrated and results from hamstring strength imbalances and lack of adequate flexibility.
Most injuries are acute. The entire length of muscle should be palpated and the injury should be classified as Mild [pulled], moderate [ partial tear] or severe [ complete rupture]. CT scan, MRI and USG are diagnostic.
Treatment consists of immobilization rest, ice; compression and elevation to control hemorrhage, pain and edema.
Administration of NSAID is controversial.
The symptoms subside quickly. Careful mobilization and pain-free stretching or strengthening exercises help to regain morbidity.
Temple HT, Kuklo TR, Sweet DE, et al [ Walter Reed Army Med Ctr, Washington, DC]
Rectus Femoris Muscle Tear Appearing as a Pseudotumor
Am J Sports Med 26: 544-548, 1998
Quadriceps femoris muscle injuries are very common in athletes. Sometimes this tear may present as a soft tissue mass on the anterior thigh, with or without a history of significant trauma.
Seven patients with unexplained soft tissue mass of the thigh were seen at a army medical centre [males between 15 and 73 years, 3 were active duty personnel, 3 were military dependents and 1, a retired serviceman. Laboratory X-rays were unremarkable. MRI showed an obvious but ill-defined mass at the musculotendinous junction of rectus. Biopsy was done in 4 patients to exclude a soft tissue sarcoma. Histologically it showed fibrosis, degeneration of muscle fibers and chronic inflammatory reaction.
These injuries could have obvious traumatic origin or possibly repeated microtrauma. The diagnosis should be suspected and selective radiologic examination performed. Full functional recovery can be expected.
Bernicker JP, Hadded JL, Lintner DM, et al [Baylor college of Medicine, Houston]
Patellar Tendon Defect During the First Year After Anterior Cruciate Ligament Reconstruction: Appearance on Serial Magnetic Resonance Imaging
Arthroscopy 14: 804-809, 1998
ACL rupture is commonly repaired using the central third of the patellar tendon. The healing process of the patellar tendon has been chronicled with the aid of MRI.
MRI scanning was done on 12 consecutive patients [ 15 to 48 years] who underwent arthroscopic ACL repair at 3 weeks, 3 months, 6 months and one year after surgery. The tendon defect was not closed, only the peritenon was sutured. The tendon gap and the patellar bone harvest site were evaluated.
Although the patellar tendon defect had decreased by an average of 62% at one year, only 2 persons had healed completely and some had not healed at all. Tendon width and length decreased. The greatest change occurred between 3 and 6 months after surgery thereafter healing showed down.
Natri A, Kannus P, Jarvinen M [UKK Inst, Tampere, Finland; Univ of Tampere, Finland; Univ of Vermont, Burlington]
Which Factors Predict the Long-term Outcome in Chronic Patellofemoral Pain Syndrome? A 7-Year Prospective Follow-up Study
Med Sci Sports Exerc 30: 1572-1577, 1998
Patellofemoral pain syndrome [PFPS] is a common sports injury that often becomes chronic. Neither conservative or operative management has yielded consistent results. A prospective study of conservative treatment has been done.
49 consecutive cases of PFPS with an average age of 27 years were given 6 weeks of conservative treatment and evaluated. The effect of 19 variables like age, sex, duration athletic activity, etc. were studied. 10 patients had surgery during the follow-up.
They conclude that systemic rehabilitation of quadriceps with a period of restriction is the treatment of choice for chronic PFPS.
Jee W-H, Choe B-Y, Kim J-M, et al [Catholic Univ, Seoul, Korea]
The Plica Syndrome : Diagnostic Value of MRI with Arthroscopic Co-relation
J Comput Assist Tomogr 22: 814-818, 1998
This is a study of the efficacy of MRI in diagnosing plica syndrome.
The MR images of 55 patients with arthroscopically confirmed pathologic mediopatellar plicae were compared with those of 100 patients without plicae.
The sensitivity and specificity of axial multiplanar gradient-recalled [MPGR] images for diagnosing plica syndrome were 73% and 83% respectively and for the combination of these images they were 95% and 72% respectively. With the criterion of extension beyond the medial end of the patella on axial MPGR images, the incidence of pathologic medial plica increased.
MRI is a useful non invasive screening tool for diagnosing plica syndrome before arthrography.
Smutz WP, Kongsayreepong A, Hughes RE, et al[ Mayo Clinic and Found, Rochester, Minn]
Mechanical Advantage of the Thumb Muscles
J Biomech 31: 565-570, 1998
The moment arms of the thumb muscles at the interphalangeal, metacarpophalangeal, and carpometacarpal joints were measured throughout the range of motion of each joint.
The technique is described and the results show that :-
1. At metacarpophalangeal joint –
FPL, FPB, ADPt and ADPo and OPP were the major flexors.
EPL, EPB were the major extensors.
ADPt, AdPo, EPL were the main adductors.
APB, and FPB were the main abductors.
2. At carpometacarpal joint –
FPL, FPB, ADPt, ADPo and OPP were the major flexors.
EDL, EPB and APL were the major extensors.
ADPt, ADPo, and EPL were the only abductors.
APB, APL and FPB were the main abductors.
This knowledge can aid in planning rehabilitation.
Lyons RP, Kozin SH, Failla JM [ US Air Force, Aviano, Air Force Base, Italy; Temple Univ, Philadelphia; Henry Ford Hosp, Detroit]
The Anatomy of the Radial Side of the Thumb: Static Restraints in Preventing Subluxation and Rotation After Injury
Am J Orthop 27: 759-763, 1998
A cadaver study was performed to delineate the anatomic variations of the radial side of the thumb MP joint and to assess the relative contributions of the volar plate, radial collateral ligament, dorsal capsule and the extensor pollicis brevis in preventing rotation and volar subluxation.
The methodology has been described. The results: The extensor pollicis brevis insertion was variable [ 61% inserted into the base of the proximal phalanx, 26% continue as a distal slip to the distal phalanx with no discrete insertion, and blending into the capsule with no discrete insertion in 10%. Volar subluxation varied from 0% to 35% and rotation from 12% to 35%. Volar subluxation increased to 26%, and rotation increased 20% when the radial collateral ligament was sectioned.
Corresponding increases after incision of the extensor pollicis brevis/dorsal capsule were 12% and 12%, and were 21% and 24% after volar plate section. When the extensor pollicis brevis/dorsal capsule was sectioned first, followed by sectioning of the radial collateral ligament and the volar plate, results were 32% and 14%, 9% and 12%, and 18% and 24% respectively.
They conclude that the radial collateral ligament and extensor pollicis brevis/ capsule help stabilize the joint against rotation and volar subluxation. An X-ray after volar displacement is more helpful than after pronation for revealing MP instability.
Griffiths GP, Selesnick FH [Miami Sports Medicine Fellowship, Coral Gables, Fla]
Operative Treatment and Arthroscopic Findings in Chronic Patellar Tendinitis
Arthroscopy 14: 836-839, 1998
Though conservative treatment is usually effective in chronic patellar tendinitis some patients continue to have symptoms, these patients may require surgery.
The authors conclude that chronic patellar tendinitis that does not respond to conservative surgery respond to surgery.
Risberg MA, Holm I, Steen H, et al [ Univ of Oslo, Norway; Martina Hansens Hosp, Baerum , Norway]
The Effect of Knee Bracing After Anterior Cruciate Ligament Reconstruction : A Prospective, Randomized Study With Two Years Follow-up
Am J Sports Med 27: 76-83, 1999
This study investigates the effects of knee bracing after ACL reconstruction on knee joint laxity, lower limb function, the cross-sectional area of the the thigh and the incidence of further intra-articular injury.
Matava MJ, Evans TA, Wright RW, et al [Washington Univ, St Louis; Slippery Rock Univ, Pa]
Septic Arthritis of the Knee Following Anterior Cruciate Ligament Reconstruction: Results of a Survey of Sports Medicine Fellowship Directors
Arthroscopy 14: 717-725, 1998
This is a review of literature regarding the incidence of septic arthritis as a complication following ACL reconstruction and its prevention and treatment.
A questionnaire was mailed to 74 surgeons listed in the Sports Medicine Fellowship Program regarding their experience and practices in performing ACL surgery, number of years in practice, number of ACL reconstructions performed annually, graft choice, surgical technique, use of postoperative drains, prophylactic antibiotics and postoperative complications in the past 2 and 5 years.
82% of responders had been in practice for an average of 17.3 years and performed an average of 98 ACL repairs annually.
77% chose the patellar tendon graft, followed by hamstring graft [23%]. Endoscopic reconstruction was the method of choice [72%] whereas 16% used arthroscopically assisted surgery. 98% used postoperative prophylactic antibiotics 51% used a drain. 30% had treated an ACL infection within the past 2 years, and 26% within the past 5 years. Culture-specific IV antibiotics and irrigation of the joint was the treatment of choice for 85% of responders. Graft removal was chosen by 31%. Revision after graft removal was done after 6-9 months by 49% of responders.
In conclusion, septic arthritis is a rare complication following ACL repair and treatment consists of culture specific IV antibiotics and joint irrigation with graft retention; with graft removal reserved for resistant infection.
Barber-Westin SD, Noyes FR, Heckmann TP, et al [Deaconess Hosp, Cincinati, Ohio; HealthSouth Rehabilitation Corp, Cincinnati, Ohio]
The Effect of Exercise and Rehabilitation on Anterior-Posterior Knee Displacements After Anterior Cruciate Ligament Autograft Reconstruction
Am J Sports Med 27: 84-93, 1999
Current trends in rehabilitation after ACL reconstruction focus on aggressive or accelerated exercise protocols with early return to full weight bearing and high levels of at athletic activity. This study analyses the results of such protocols.
Individual evaluation based rehabilitation is needed after ACL reconstruction.
Carson WG Jr, Gasser SI [Sports Medicine Clinic of Tampa, Fla; Florida Orthopaedic Inst, Tampa]
Little Leaguer’s Shoulder: A Report of 23 Cases
Am J sports Med 26: 575-580, 1998
The exact etiology is unknown.
This clinical entity occurs in juvenile or adolescent baseball players with throwing-related pain localized to the proximal humeral and the radiographic fining of widening of the proximal humeral physis.
All complained of pain localized to the proximal humerus during the act of throwing.
All patients had radiographic widening of the proximal humeral physis of the throwing arm of internal and external rotation comparison anteroposterior radiographs of the shoulders.
Patients at risk are adolescents around age 14 years who have played continually for several months.
Patients usually experienced localized pain at the proximal lateral humerus.
Classic radiographic findings include widening of the proximal humeral physis with associated calcification or lateral fragmentation that is easily detected on bilateral anteroposterior internal and external rotation comparison radiographs of the proximal humerus
Fischer DA, Tewes DP, Boyd JL, et al [Minneapolis Sports Medicine Ctr]
Home-based Rehabilitation for Anterior Cruciate Ligament Reconstruction
Clin Orthop 347: 194-199, 1998
The results of a postoperative home based rehabilitation program after ACL reconstruction were compared with the results of a traditional clinic-based program.
During a 2 year period, 54 patients were randomly assigned to a home based [n=27] program or to a traditional clinic based program [n=27]. There was a minimum of 6 weeks between injury and reconstruction. The home based program patients had supervised visits at 1,2,3,4,6 and 12 weeks. The clinic based group had 24 appointments in the first 6 months. Pre and postoperative Lysholm and health status questionnaire scores were recorded.
The Lysholm scores, physical examination results, the hop test, KT-1000 test and HSQ results were similar for the 2 groups.
The home based rehabilitation program after ACL reconstruction provides good, cost-effective results.
Dye SF, Wojtys EM, Fu FH, et al [Univ of California, San Francisco; Univ of Michigan, Ann Arbor; Univ of Pittsburgh, Pa et al]
Factors Contributing to Function of the Knee Joint After Injury or Reconstruction of the Anterior Cruciate Ligament
J Bone Joint Surg Am 80-A: 1380-1393, 1998
The factors that govern restoration of knee function after injury or ACL reconstruction are discussed in terms of musculoskeletal function.
This concept encompasses the capacity to generate, transmit, absorb and dissipate loads and to maintain homeostasis.
Several factors contribute to the functional capacity of a joint. These include  anatomical factors, like macromorphology and micromorphology, structural integrity, and biomechanical characteristics.  Kinematic factors, such as pattern of sequential tightening of the ACL fibers and the dynamics of all the complex neuromuscular control mechanisms  Physiologic factors, such as the biochemical and metabolic processes that maintain homeostasis in the joint and musculoskeletal components. And [ 4] Non operative or operative treatments.
Absence of pain, warmth, swelling and functional instability indicate that a joint is not being overloaded.
Tieschky M, Faber S, Haubner M, et al [ Ludwig-Mximilians Universitat Munchen, Germany; Klinikum Grobhadern, Munich, Germany; Institut for Medizinische Informatik und Systemforschung, Neuherberg, Germany; et al]
Repeatability of Patellar Cartilage Thickness Patterns in the Living, Using a Fat-suppressed Magnetic Resonance Imaging Sequence With Short Acquisition Time and Three-Dimensional Data Processing
J Orthop Res 15: 808-813, 1997
Potter HG, Linklater JM, Allen AA, et al [ Hosp for Special Surgery, New York City ]
Magnetic Resonance Imaging of Articular Cartilage in the Knee : An Evaluation With Use of Fast-Spin-Echo Imaging
J Bone Joint Surg Am 80-A: 1276-1284, 1998
The best MRI sequence for detection of chondral abnormalities remains unclear. This study evaluates a specialized proton density weighted high resolution fast spin echo sequence for evaluation of chondral pathology.
This method provides a valuable approach for evaluation of chondral pathology.
Wright JG, Hawker GA, Bombardier C, et al [Univ of Toronto; Sunnybrook & Womens College Hosp, North York, Ont; Vanderbilt Univ, Nashville, Tenn; et al]
Physician Enthusiasm as an Explanation for /area Variation in the Utilization of Knee Replacement Surgery
Med Care 37: 946-956, 1999
This study examines the variation in the utilization of knee replacement surgery by county in the Canadian province of Ontario. The factors evaluated included the characteristics and opinions of the physicians and specialists, severity of disease, access to the procedure, use of alternative surgery and population factors.
Knee replacement was more frequently used in older patients and in medical school affiliated hospitals. The referring physicians were usually males, trained outside North America. Orthopedic surgeons had a higher propensity for performing knee replacements and better perceptions of the outcomes.
The authors conclude that the local orthopedic surgeons have a major influence on the rate of knee replacement in a given geographic area. Efforts to reduce variation in surgeon opinion might reduce although not eliminate, geographic variation.
Coyte PC, Hawker G, Croxford R, et al [Univ o Toronto; Womens College Hosp, Toronto; Hosp for Sick Children, Toronto]
Rates of Revision Knee Replacement In Ontario, Canada
J Bone Joint Surg Am 81-A: 773-782, 1992
This analysis includes 18,520 knee replacements performed in Ontario from 1984 to 1991. One study algorithm was used to identify primary versus revision
knee replacements and another was used to link revision to primary knee replacements.
The survival of the primary knee replacements was assessed using the Kaplan Meier method and factors affecting survival were identified using a proportional hazards regression model.
Overall 7% of the total number of knee replacements were revisions. Osteoarthritis was the commonest indication for primary knee replacement. The time to revision surgery was significantly longer for patients older than 55 years, rural population and in those with rheumatoid arthritis revision.
Revision replacement surgery was done earlier in teaching or speciality hospitals. Long term revision rates were low. The estimated rate of revision within 7 years varied significantly according to the algorithm used from 4.3% to 9%.
They conclude that revision knee replacement is a rare event. Many factors affect thus likelihood like age, sex, area of residence and type of hospital.
Robertsson O, Borgquist L, Knutspm K, et al [Univ Hosp, Lund, Sweden; Linkoping Univ, Sweden]
Use of Unicompartmental Instead of Tricompartmental Prostheses for Unicompartmental Arthrosis in the Knee is a Cost-effective Alternative : 15,437 Primary Tricompartmental Prostheses Were Compared With 10,624 Primary Medial or Lateral Unicompartmental Prostheses
Acta Orthop Scand 70: 170-175, 1999
This study evaluates the cost of UKA [Unicompartmental] and TKA [Tricompartmental] procedures including implant cost. Length of hospital stay and the difference in the number of expected revisions.
The analysis included 15,437 primary TKAs and 10,624 primary medial or lateral UKAs over an 11 year period. Registry data was used to compare length of hospital stay in the 2 groups. Survival data was used to calculate the
cumulative revision rate [CRR] and relative risk of revision. The risk of second revision and infection were calculated as well.
The proportion of patients undergoing UKA implantation declined during the period of study. The average age at primary operation was 73 years [TKA] and 71 years [UKA]. The postoperative stay averaged 12.3 days [TKA] and 10.7 days [UKA]. The 10 year CRR was 12% [TKA] AND 16% [UKA]. The rate of serious complications was significantly lower in UKA group. The cost of a UKA was 57% that of TKA procedure.
The conclusion is that the cost of UKA implantation is lower than TKA implantation [inclusive of higher revision rate]. It also has a shorter hospital stay. The costs may be further reduced by proper selection of patients.
Parentis MA, Rumi MN, Deol GS, et al [Pennsylvania State Univ, Hershey]
A Comparison of the Vastus Splitting and Median Parapatellar Approaches in Total Knee Arthroplasty
Clin Orthop 367 : 107-116, 1999
This is a controlled prospective study [randomized] comparing the two approaches.
42 consecutive patients [51 knees] with degenerative disease of the knee were subjected to TKA.
The median parapatellar approach used a standard midline incision. In the vastus medialis splitting approach the same incision was used; however at the level of the supero medial corner of the patella, the vastus medialis fascia was incised along the margin of the quadriceps tendon and elevated medially. The muscle was then split bluntly.
Electromyography performed pre and postoperatively was used to evaluate the two approaches relative to their effect on the innervation of the quadriceps mechanism.
The two randomized groups were similar in age, weight and other clinical parameters. Postoperatively, no significant differences were noted during the hospital stay at 2, 6 and 12 weeks in terms of straight leg raise, ROM and hospital for special surgery scores, short arc quadriceps strength or tourniquet time. Blood loss was significantly greater in the standard approach [ 200 vs 129.6 ml]. 9 patients [43%] who had vastus splitting approach had abnormal postoperative electromyograms.
The two approaches are similar when compared clinically. Longer tern studies, however, are needed to determine the clinical significance of denervation of the vastus medialis muscle by the vastus splitting approach.