The American Journal of Sports Medicine

We present a series of 19 avulsions of the distal tendon of the biceps brachii muscle after a follow-up of 2 to 11 years. Ten patients with delayed diagnosis and treatment (3 weeks to 5 months) were compared with nine patients treated early (within 8 days after injury). Excellent or good results at follow-up were obtained in 9 of 10 patients in the delayed-treatment group and in all 9 patients in the early-treatment group. Nine of 10 patients in the delayed-treatment group and all patients in the early-treatment group had been able to return to their preinjury levels of activity. For reference, a meta-analysis of 147 cases reported previously was performed. Ninety percent of the patients treated with an anatomic reinsertion had excellent or good results after an average follow-up of 3 years, while similar results after 3 years were seen in 60% of the patients who had nonanatomic tendon reinsertion and in 14% of the patients who were treated nonoperatively. The delay of up to 3 years between injury and anatomic reinsertion had not compromised the result. From these data we concluded that anatomic reinsertion of the avulsed distal biceps tendon to the radius is the preferred treatment in acute as well as chronic injuries.

A long-term follow-up was performed on 22 patients treated for a posterior glenoid osteophyte and symptomatic posterior shoulder pain during either the late cocking, acceleration, or follow-through phases of throwing. Arthroscopic evaluation of these patients revealed undersurface tearing of the rotator cuff in all but one. Fifteen patients also had tearing of the posterior labrum. Anterior labral fraying was noted in four patients. Treatment consisted of debridement of the rotator cuff and labral tears. The posterior glenoid osteophyte was removed arthroscopically in 11 patients. Eighteen of 22 throwers treated were available for long-term follow-up at a mean of 6.3 years (range, 1 to 12). Only 10 of 18 (55%) throwers evaluated had returned to their premorbid level of throwing. All 10 were asymptomatic and had maintained a high level of performance for a mean of 3.6 years (range, 1 to 8). At the time of latest follow-up, five players were still participating at the major league level and five had retired. One patient had recurrence of the exostosis 8 years after surgery. Among our patients a trend existed toward a poorer result and failure of return to activity with a posterior osteophyte greater than 100 mm2. A posterior glenoid exostosis, when identified in the symptomatic shoulder of the throwing athlete, can be considered a definite marker of internal impingement.

We prospectively evaluated the usefulness of a new pain provocation test to diagnose superior labral tears in 32 patients with diagnosed throwing injuries of the shoulder. Results of the pain provocation test were compared with findings on magnetic resonance arthrography (all 32 patients) and arthroscopic examination (15 patients). In 22 patients, detachment of the superior labrum was observed on arthrograms, and all of them had positive results on the new pain provocation test. Nine of the other 10 patients had negative results on the new pain provocation test. However, 1 of the 10 patients had a positive result. Eleven of 15 patients were found to have superior labral lesions arthroscopically, and all of them were classified as type II superior labral anterior posterior lesions. All the 11 patients had positive pain provocation tests. The other four patients without superior labral tears on arthroscopic findings had negative results on the new pain provocation test. The new pain provocation test identified all patients with detachment of the superior labrum confirmed by magnetic resonance arthrography, for a sensitivity of 100%, a specificity of 90%, and an accuracy of 97%. Results of the new pain provocation test were in accord with arthroscopic findings in the 15 patients who underwent arthroscopic examination.

Ankle injuries frequently occur in dancers. Among these injuries, only a few cases of talar subluxation have been reported in the literature. In our series, we diagnosed and treated 25 subtalar subluxations over a 1-year period in the Ballet Béjart Lausanne company. The subluxations occurred after a grand plie on pointes or at the landing of a jump on demi-pointes, without any mechanism of ankle sprain. The dancer usually noted a sudden and sharp pain in the talonavicular joint and hindfoot with a feeling of “forward displacement” of the foot. At palpation, the talonavicular ligament, the anterior talofibular ligament, and the posteromedial part of the subtalar joint were painful. A limitation of the ankle extension and a clear hypomobility of the subtalar joint were noted. Under the effect of shearing forces on the midtarsal joint, a posteromedial subtalar subluxation occurred. Treatment consisted of a manipulation that reduced the subluxation. Continuous taping, which locks the talonavicular joint in the anterior direction, was recommended for 6 weeks. Dancing could be resumed in a swimming pool after 2 weeks, and on the ground after 3 to 4 weeks. We found that subluxation could recur, and that it could eventually become chronic.

We studied the effect that chronic anterior cruciate ligament disruption, functional bracing, and a neoprene sleeve have on knee proprioception by measuring the threshold to detection of passive knee motion in all three conditions. The threshold to detection of passive knee motion was worse in knees with chronic anterior cruciate ligament insufficiency when compared with uninjured knees. This difference was small, on average an additional 0.28° of flexion-extension rotation was required for the anterior cruciate ligament-deficient knee before the subject detected motion, and of questionable significance from a clinical and functional perspective. Wearing a functional brace or neoprene sleeve on the anterior cruciate ligament-deficient knee did not significantly change the threshold to detection of passive motion in comparison with the same knee without a brace, although improvements were observed. There was no relationship between the most common clinical means of characterizing altered bio-mechanics of the anterior cruciate ligament-deficient knee (that is, the magnitude of anterior-posterior knee laxity and the grade of pivot shift) and the threshold to detection of passive knee motion.

We sought to determine whether participation in a functional sports agility program as early as 4 weeks after anterior cruciate ligament reconstruction with autogenous patellar tendon graft would affect objective knee stability in 603 patients. The rehabilitation program prescribed a functional sports agility program at a mean of 5.1 1.0 weeks postoperatively when full knee hyperextension, knee flexion to 120°, and quadriceps muscle strength of 60% of the normal leg had been achieved. The patients had KT-1000 arthrometer testing before beginning the program and at subsequent follow-up after they had performed the sport activity. The mean manual maximum KT-1000 arthrometer difference was 1.9 1.3 mm at initial testing and 1.9 1.2 mm at follow-up testing. The frequency distribution of the KT-1000 arthrometer scores revealed that 92.7% of patients at initial testing and 93.2% of patients at follow-up testing had displacement difference of 3 mm or less. The results of this study show that functional sports agility programs during the early rehabilitation period after anterior cruciate ligament reconstruction with a correctly placed autogenous patellar tendon graft do not cause a change in graft stability.

Glenohumeral joint capsule obtained from 42 patients who had undergone an arthroscopic laser-assisted capsular shift procedure was evaluated histologically. A total of 53 samples from the anterior inferior glenohumeral ligament of the joint capsule were collected before and at various times after the procedure (range, 0 to 38 months). Despite glenohumeral instability, joint capsule of the patients before the procedure showed no significant histologic lesions. Laser treatment significantly altered the histologic properties of the tissue as evidenced by hyalinization of collagen and necrotic cells (time 0). Tissues sampled during the short-term period (3 to 6 months) after the procedure demonstrated fibrous connective tissue with reactive cells and vasculature. Collagen and cell morphology returned to normal in the middle- to long-term period (7 to 38 months) after the procedure, while the number of fibroblasts remained elevated. Joint capsule collected from the shoulders of six patients who experienced stiffness after the procedure showed persistent synovial, cellular, and vascular reaction even after 1 year postoperatively, the cause of which is unclear. This study re-

The purpose of this study was to determine the effects of laser-induced collagen shortening on the biomechanical properties of the inferior glenohumeral ligament complex. Fifty-seven bone-ligament-bone specimens underwent uniaxial tensioning to 10% strain. Approximately half of the specimens then underwent 10% shortening by lasing using a holmium:yttrium-aluminum-garnet laser. Both groups were again tensioned to 10% strain, and then loaded to failure. Ultimate strain and yield strain were significantly higher in the lased specimens than in the nonlased specimens. No significant difference was found for ultimate stress, yield stress, or elastic modulus between the two groups. Failure of the ligament did not appear to occur in the lased areas. The load-to-failure results suggested that the strength of the ligament complex was not significantly compromised by this lasing protocol.

The purpose of this intervention study was to prove that increasing flexibility of the hamstring musculotendinous unit would decrease the number of lower extremity overuse injuries that occur in military infantry basic trainees. Two different companies going through basic training at the same time were used. Hamstring flexibility was checked at the beginning and at the end of the 13-week infantry basic training course. The control company (N 148) proceeded through normal basic training. The intervention company (N 150) followed the same program but added three hamstring stretching sessions to their already scheduled fitness program. All subsequent lower extremity overuse injuries were recorded through the troop medical clinic. Hamstring flexibility increased significantly in the intervention group compared with the control group. The number of injuries was also significantly lower in the intervention group. Forty-three injuries occurred in the control group for an incidence rate of 29.1%, compared with 25 injuries in the intervention group for an incidence rate of 16.7%. Thus, in this study, the number of lower extremity overuse injuries was significantly lower in infantry basic trainees with increased hamstring flexibility.

Spinal injuries are among the most devastating injuries associated with recreational sports. Snowboarding spinal injury patterns have not been described. During two seasons (1994 to 1995 and 1995 to 1996), 34 skiers and 22 snowboarders suffered serious spinal injuries (fracture or neurologic deficit or both) at two ski areas in British Columbia, Canada. Ski patrol records, the Provincial Trauma Database, and hospital records were reviewed. Injury rates were based on computerized lift-ticket data and a population estimate of 15% snowboarders (ski patrol observation). The incidence of spinal injury among skiers was 0.01 per 1000 skier-days, and among snowboarders was 0.04 per 1000 snowboarder-days. Mean age was 34.5 years for skiers and 22.4 years for snowboarders. Seventy percent of the skiers were men, whereas all of the snowboarders were men. Jumping (intentional jump 2 meters) was the cause of injury in 20% of skiers and 77% of snowboarders. Neither age nor sex accounted for any significant portion of this difference. The rate of spinal injuries among snowboarders is fourfold that among skiers. Although jumping is the primary cause of injury, it is an intrinsic element of snowboarding. Until research defines effective injury-prevention strategies, knowledge of the risk of snowboarding should be disseminated and techniques for safe jumping should be taught.

Ten patients who underwent anterior cruciate ligament reconstruction by one surgeon using autologous patellar tendon grafts were evaluated. A standardized technique of performing a notchplasty was done to remove at least 5 mm of bone at the anterior outlet of the intercondylar notch. Computed tomography scans were done preoperatively, within 1 week postoperatively, and after 1 year of follow-up. There were no statistically significant differences in the measured dimensions of the intercondylar notch between 1 week and 1 year postoperatively. While previous investigations have evaluated the relationship between intercondylar notch dimensions and risk of anterior cruciate ligament injury, we believe this is the first statistical study that addresses the natural history of the intercondylar notch in humans after bone resection. We believe that the data reported here may enhance our understanding and treatment of patients who have undergone previously failed anterior cruciate ligament reconstructions.

We reviewed the results in 13 patients who underwent simultaneous allograft reconstruction of both the anterior and posterior cruciate ligaments after a knee dislocation (nine acute and four chronic injuries). Seven patients sustained related medial collateral ligament injuries and six patients had posterolateral complex injuries. Ligament reconstructions were performed using fresh-frozen Achilles or patellar tendon allografts. At follow-up evaluation (mean of 38 months), only one patient described the reconstructed knee as normal. Six patients had returned to unrestricted sports activities and four had returned to modified sports. The average extension loss was 3° (range, 0° to 10°) and average flexion loss was 5° (range, 0° to 15°). The KT-1000 arthrometer measurements at 133 N anterior-posterior tibial load showed a mean side-to-side difference of 4.5 mm (range, 0 to 10) at 20° and 5.0 mm (range, 0 to 9) at 70°. The mean Lysholm score was 88 (range, 42 to 100). International Knee Documentation Committee ratings were six nearly normal, five abnormal, and one grossly abnormal. Two patients required manipulations for knee stiffness. This study demonstrates that reconstruction of both cruciate ligaments can restore stability sufficient to allow sports activity in most patients with knee dislocations, but “normal” results are difficult to achieve.

Our experience in treating chronic lower-leg compartment syndrome suggests that women may be more susceptible to this injury than are men, an observation for which there is support in the literature. Furthermore, when we evaluated the 47 young female athletes (age range, 13 years 11 months to 21 years 10 months) from our practice on whom 78 separate surgeries were performed, we found a lower success rate than those generally reported in studies that combine male and female patients. We suspect, therefore, that for reasons as yet unclear, women may also respond less well than men to operative fasciotomy.

Biomechanical testing was done on 15 matched pairs of central-third bone-patellar tendon-bone and double-looped semitendinosus-gracilis grafts harvested from 15 cadaveric knees. Load to failure, composite graft stiffness, and the modulus of elasticity were calculated for each graft. Specimens were from 2 female and 13 male donors (average age, 40 years; range, 17 to 53). Average load to failure for the patellar tendon grafts was 1784 N ( 580), compared with 2422 N ( 538) for the hamstring tendon grafts (significantly different). There was no statistically significant difference in stiffness between grafts (patellar tendon, 210 N/mm; hamstring tendon, 238 N/mm). The elastic modulus was 225 MPa ( 129) for the patellar tendon grafts and 145 MPa ( 58) for the hamstring tendon grafts (significantly different). The average cross-sectional area for the hamstring tendon grafts was 57 mm2, compared with the 45 mm2 for the patellar tendon grafts. The hamstring tendon grafts were significantly stronger than the matched central-third patellar tendon grafts, but the two grafts were similar in stiffness. The patellar tendon grafts had a higher modulus than the hamstring tendon grafts.

Previous studies report that noncontrast magnetic resonance imaging is limited in the evaluation of the superior glenoid labrum. From our magnetic resonance imaging database of 2552 patients, we prospectively identified 104 patients with superior labral lesions who subsequently went on to arthroscopic surgery. Magnetic resonance images were assessed to identify fraying, flap tears, bucket-handle tears, or displaced flap of fibrocartilage. The biceps tendon was also evaluated. Patients were categorized according to Snyder's classification, and the findings on the magnetic resonance images were correlated with surgical findings. One hundred of the 104 tears suspected on the images were confirmed at surgery. There were four false-positives and two false-negatives, the former reflecting one normal labrum, two meniscoid-type labra, and one sublabral foramen. With arthroscopic surgery as the standard, magnetic resonance imaging had a sensitivity of 98.0% (100 of 102), a specificity of 89.5% (34 of 38), and an accuracy of 95.7% (134 of 140) for detection of superior labral lesions. We concluded that high-resolution noncontrast magnetic resonance imaging can accurately diagnose superior labral lesions and aid in surgical management.

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.

Muscle laceration remains a difficult problem for orthopaedic surgeons. Despite many studies related to the muscle's ability to regenerate after muscle degeneration, very few reports are available regarding structural and functional recovery after skeletal muscle laceration. We developed an animal model of muscle laceration in mice, where the gastrocnemius muscles were reproducibly transected. We compared the effect of a surgical repair versus a short period of immobilization (5 days) on the muscle healing. The natural course of muscle recovery was monitored at several points after injury using histologic, immunohistochemical, and functional testing. In the injured muscle, we observed a high number of regenerating myofibers and development of fibrotic scar tissue. Suturing the lacerated muscle immediately after injury promoted better healing of the injured muscle and prevented the development of deep scar tissue in the lacerated muscle; conversely, immobilization resulted in slower muscle regeneration and the development of a large area of scar tissue. Tetanus strength 1 month after injury was 81% of control muscles for the sutured muscles, 35% for the lacerated muscles with no treatment, and 18% for the immobilized muscles. Based on this study, suturing a muscle laceration with a modified Kessler stitch results in the best morphologic and functional healing.