Shoulder proprioception: a comparison between the shoulder joint in healthy and surgically repaired shoulders

Proprioceptive mechanisms appear to play a role in stabilizing the glenohumeral joint and may serve as a means for interplay between the static stabilizers and the dynamic muscle restraints. The aim of this study was to investigate proprioception of the joint in healthy and surgically repaired shoulders. Shoulder proprioception was measured in 44 subjects who were assigned to two experimental groups: group 1, healthy subjects (n = 24); and group 2, patients who have undergone surgical reconstruction (n = 20). Joint position sense was measured with a Cybex NORM isokinetic dynamometer. The results revealed no significant differences in proprioception between the dominant and nondominant shoulders in group 1. No significant mean differences were revealed between the surgical and contralateral shoulder in group 2 under any test condition. These results imply that arm dominance in healthy individuals does not influence the proprioceptive sensibility and that reconstructive surgery appears to restore some of these proprioception characteristics.     

膝关节半月板损伤的手术修复疗效观察

目的探讨切开直视下及关节镜下缝合修复半月板损伤的疗效及术后并发症发生情况。方法1988年1月～2004年6月采用切开直接缝合法和关节镜下缝合修补方法修复半月板损伤168例170个。关节镜下方法包括穿刺打磨修复法、可吸收半月板箭复位固定法、Outside-In缝合法、Inside-Out缝合法、Elite肩袖缝合器缝合法、T-Fix固定技术和FasT-Fix固定技术。通过症状、体征、Tegner和Lysholm评分对半月板缝合修复的临床效果进行评价,并对术后的并发症进行观察。对有明显症状及体征的患者进行关节镜探查。结果所有患者获得6个月～9．5年(平均49．3±28．8个月)随访发现,Tegner评分：术前3．3±2．3,术后6．8±2．1(p＜0．05)。Lysholm评分：术前30．1±18．2,术后87．5±22．5(P＜0．01)。按Molster对Lysholm评分的分级方法,优98个,良57个,可10个,差5个,优良率为91．2%。对术后症状和体征明显的19例患者进行关节镜再探查,发现5例术愈合,6例部分愈合。术后并发症包括Outside-In缝线打结处疼痛3例,外侧半月板前角Outside-In缝合后未愈合导致后关节囊牵拉痛1例,半月板箭固定处的后关节囊刺痛5例。无严重血管、神经损伤,术后并发症的总发生率为5．3%。结论选择适当方法对损伤半月板进行修复可明显改善膝关节的症状和功能评分,并且具有较高的手术成功率和较少的术中、术后风险。     

Arthrotomography of the unstable shoulder

Thirty-seven patients suffering from clinically verified subluxation of the shoulder joint underwent double-contrast arthrotomography. Sixteen of these patients were operated on, 4 of whom after arthroscopy, and 1 patient had only arthroscopy. Arthrotomography readily revealed lesions of the glenoid labrum, most of them small, and also redundancy of the anterior joint capsule. The method can be recommended in the examination of the glenoid labrum in patients suffering from anterior subluxation of the shoulder.     

The epidemiology of surgically repaired aneurysms in the United States.

OBJECTIVE: The purpose of this study was to determine the results of surgery for hospitalized cases of aneurysms in the United States, thereby providing a standard of comparison for new techniques proposed to treat aneurysms. METHODS: Data on hospitalized aneurysm cases were collected from the National Hospital Discharge Survey, a comprehensive database of patients hospitalized in the United States for treatment from the years 1984 to 1994. The National Hospital Discharge Survey samples non-federal, acute-care hospitals with an average length of stay of less than 30 days. All the cases had a diagnosis of or a surgical procedure for a non-cerebral aneurysm. RESULTS: In the year 1994, 51,949 non-cerebral aneurysms were repaired in the United States, and 75% of these procedures were abdominal aortic aneurysm (AAA) surgeries. The operative mortality rates for AAA were higher than previously reported from multi-institutional studies and were found to be 8.4% for elective repair and 68% for emergency AAA repair. The number of aneurysm surgeries per thousand population varied by region: surgery rates were more frequent in the Northeast and less frequent in the West. Surgical volume appeared to decrease for smaller hospitals and increase for larger hospitals for the period between 1990 and 1994. The overall mortality rates for all aneurysm surgeries diminished with hospital size. However, no significant difference was found for the rates of elective AAA repair between hospital sizes. The percentage of men with aneurysms who underwent surgery for repair was significantly higher than for women with aneurysms. In addition, the AAA repair rates increased for men from 1985 to 1994, and the number of women reported with repaired AAAs remained constant. CONCLUSION: The location of aneurysm, urgency of repair, region, sex, and hospital size are important factors related to patient treatment and outcome. These data provide a standard of comparison against which surgeons can compare their own results, and they provide a benchmark for the evaluation of interventional techniques proposed to treat aneurysms.     

Osteoarthrosis after the Max Lange procedure for unstable shoulders

Summary. Thirty-four patients were followed for a mean of 14.4 years after the Max Lange operation for instability of the shoulder. This procedure consists of an anterior capsulorraphy with lateralisation of the subscapularis tendon and the insertion of a bone block at the inferior and anterior part of the glenoid. The Rowe score showed 87% good and excellent results. External rotation and abduction were significantly limited as compared to the normal side. Radiographs revealed osteoarthrosis in 47%. Double contrast computed tomography in 18 cases showed a bony defect in the anterior and inferior part of the humeral head in 12 who had significantly limited external rotation as compared to those without the defect. Lateralisation of the subscapularis tendon with limitation of external rotation may lead to increased contact stress and shear forces at the anterior rim of the glenoid which contributes to the development of osteoarthrosis.

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Résumé. Trente quatre patients, après avoir été operés selon la méthode de Max Lange (imbrication du tendon souscapulaire et greffe d’un bloc osseux au niveau antéro-inférieur de la glène) ont été suivi pendant une durée moyenne de 14,4 ans. Le score de Rowe révela que les résultats ont été positifs et excellents à 87% (quatre vingt sept pour cent). La rotation externe et l’abduction ont été assez limitées (p <0,05) par rapport à l’épaule non operée. Une radiographie révela chez 47% (quarante sept pour cent) des patiens une arthrose de l’épaule concernée. La tomographie par ordinateur à double contrastes (n = 18) a révelé chez 12 (douze) patients un défect antéro-inférieur de la tête humérale et chez ces mêmes patients une rotation externe limitée en comparaison avec les patients ne présentant pas la même anomalie osseuse (p = 0,04). On suppose qu’une latéralisation du tendon souscapulaire avec limitation de la rotation externe entraine une augmentation de la force de contact et de frottement sur le bord antérieur de la glène par laquelle est favorisée l’arthrose de l’épaule.

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Accepted: 1 February 1997     

Glenohumeral osteometry by computed tomography in normal and unstable shoulders

Past radiologic and anthropometric studies report a high incidence of glenoid anteversion and increased humeral retrotorsion in patients with recurrent anterior dislocation (RAD) of the shoulder. However, recent radiologic studies do not demonstrate significant developmental variations between normal and unstable shoulders. To investigate these conditions, the authors used computed tomography (CT), which offered the advantage of permitting a transverse view at different levels of the glenohumeral joint. CT also avoided the typical distortion inherent in plain radiographs performed in the axial projection. No significant developmental differences in glenohumeral index, glenoid anteroposterior orientation, and humeral retrotorsion were found between 50 normal subjects and 40 patients with RAD. Only erosions and fractures of the glenoid may affect orientation and anteroposterior diameter of the glenoid. Mainly, traumatic lesions rather than developmental abnormalities seem to affect these parameters in RAD patients.     

Skin temperature of the shoulder: Circadian rhythms in normal and pathologic shoulders

Circadian rhythm of the shoulder skin temperature was studied in 21 shoulders of 20 patients with rotator cuff tears (average age, 58 years) and 4 shoulders of 4 patients with rotator cuff tendinitis (average age, 34 years). Fourteen of the 23 uninvolved shoulders with no abnormalities on magnetic resonance imaging were also studied as normal shoulders. With a portable thermometer with the probes attached to the anterior surface of both shoulders, the skin temperature was recorded every 5 minutes from 1:00 pm to 9:00 am (20 hours). Both the normal and cuff tear shoulders showed a stimilar circadian rhythm with the temperature at night significantly lower than the temperature during the daytime (P < .0001). On the other hand, the tendinitis shoulders did not show this circadian rhythm; the temperature did not change significantly through the range of measurement. We conclude that the skin temperature shows a circadian rhythm in normal shoulders, and this rhythm may be affected by certain pathologic conditions of the shoulder.     

Outcome of repaired unstable meniscal tears in children and adolescents

Background

Unstable meniscal tears are rare injuries in skeletally immature patients. Loss of a meniscus increases the risk of subsequent development of degenerative changes in the knee. This study deals with the outcome of intraarticular meniscal repair and factors that affect healing. Parameters of interest were type and location of the tear and also the influence of simultaneous reconstruction of a ruptured ACL.

Methods

We investigated the outcome of 25 patients (29 menisci) aged 15 (4–17) years who underwent surgery for full thickness meniscal tears, either as isolated lesions or in combination with ACL ruptures. Intraoperative documentation followed the IKDC 2000 standard. Outcome measurements were the Tegner score (pre- and postoperatively) and the Lysholm score (postoperatively) after an average follow-up period of 2.3 years, with postoperative arthroscopy and MRT in some cases.

Results

24 of the 29 meniscal lesions healed (defined as giving an asymptomatic patient) regardless of location or type. 4 patients re-ruptured their menisci (all in the pars intermedia) at an average of 15 months after surgery following a new injury. Mean Lysholm score at follow-up was 95, the Tegner score deteriorated, mean preoperative score: 7.8 (4–10); mean postoperative score: 7.2 (4–10). Patients with simultaneous ACL reconstruction had a better outcome.

Interpretation

All meniscal tears in the skeletally immature patient are amenable to repair. All recurrent meniscal tears in our patients were located in the pars intermedia; the poorer blood supply in this region may give a higher risk of re-rupture. Simultaneous ACL reconstruction appears to benefit the results of meniscal repair.Isolated meniscal tears in the skeletally immature patient are rare but well-recognized injuries (Hede et al. 1990). Meniscal tears are frequently seen in association with a ruptured ACL (Bellisari et al. 2011, Samora et al. 2011). The menisci reduce contact stress and buffer axial, rotational, and shearing forces, thereby protecting the articular cartilage (Kurosawa et al. 1980). In the classic paper by Fairbank (1948), early osteoarthritis was clearly shown to be the inevitable outcome of total medial menisectomy. This led to the development of various techniques of meniscal repair in order to improve long-term outcome. This is particularly desirable in the immature patient, as early degenerative changes in this population have profound consequences in the long term. There are a variety of all-inside arthroscopic techniques that are relatively easy to master and that can be quick to perform as compared to the more technically demanding inside-out and outside-in methods (Haas et al. 2005, Kotsovolos et al. 2006).The results of meniscal repair in adults have been reported to be fair to good (Barber 1987, Eggli et al. 1995), while there have been few published data for children and adolescents (Krych et al. 2008). In this retrospective study, we assessed the outcome in a cohort of children and adolescents undergoing meniscal repair and determined whether there was any relationship between the type of meniscal injury and the outcome.     

Shoulder dislocation associated with humeral fracture on the same side (unstable shoulder joint)

The joint instability observed at the dislocation of the shoulder and the humeral fracture on the same side are described. The idea of "unstable shoulder joint" is used and the operative indication of the shoulder dislocation is outlined.     

Temporary extra-articular Bosworth' fixation in complete shoulder joint separation. Follow-up results of 41 surgically treated patients

41 patients were reviewed who suffered from complete separation of the acromioclavicular joint which was operated on with an extraarticular clavicular coracoid fixation by means of a Bosworth screw. In 82% of the cases a subjective and functionally good to excellent result was found. Only one patient complained about difficulties in managing daily life. One patient showed a subluxation of the acromioclavicular joint in X-ray with 10kp extension, all other patients demonstrated stabile relations of the ligaments. The coraco-clavicular calcifications of the ligaments increased with the number of months after operation without a negative influence on functions. An operation without much irritation and in a short period of time, the early beginning of functional therapy and the impressive results of the review show that the technique after Bosworth appears superior to other comparable procedures.     

Bone mineral density of the shoulder joint in frozen shoulder

The purpose of this study was to evaluate the osteopenia in several parts of the shoulder joint in a series of individuals suffering from frozen shoulder and to elucidate the pathogenesis. The bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA). In 30 cases of frozen shoulder, 16 men and 14 women, BMD of the head of the humerus, greater tubercle of the humerus, surgical neck of the humerus, and neck of the scapula was evaluated. The average age of the male patients was 58.4 years and of the women, 59.5 years. At the neck of the scapula, there were no significant differences in any of the cases. However, there was a marked decrease in BMD at the proximal end of the humerus on the affected side of women. In contrast, men showed no significant difference between the affected and unaffected shoulders, suggesting that the degree of osteopenia remains low compared with women. Although frozen shoulder is a disease which may occur in both men and women, the loss of bone was conspicuous only in women. This may be due to the involvement of female hormones in alterations of bone in frozen shoulder, as in cases of osteoporosis, in addition to the originally low bone density in women. The degree of osteopenia of the proximal humerus with frozen shoulder was not correlated with the duration of the disease, range of motion of the shoulder joint, or patient's age.     

Use of remifentanil in an infant with surgically repaired Shone's syndrome

We describe the use of remifentanil in an infant with a partially repaired Shone's syndrome who required tendon lengthening because of congenital clubfoot. Remifentanil has unique properties, making it a potentially useful and predictable agent for infants with significant comorbidity.     

Biometric analysis of the unstable shoulder]

An osteometry of instable glenohumeral-joints was done by computerized tomography. In comparison of type and direction of the instability, a marked retroversion of the glenoid was found in posterior luxation, not only in the instable, but also in the contralateral side. There seems no statistical prove of an influence by a changed radius or width of the humerus-head nor by a reduced retrotorsion of the humerus. Posttraumatic disorders like HILL-SACHS-lesions or BANKART-lesions are more easily detected by computerized tomography than by conventional radiography.     

Tuberculosis of the shoulder joint

In contrast to specific shoulder girdle processes tuberculoses of the shoulder joint are observed relatively frequently. From 1955 up to and including 1980, 50 patients with omarthritis tuberculosa were surgically treated at the authors' clinic. Thirty were male, 20 female, 42 were Germans, 8 immigrant workers. Arthrodeses were performed in 28 cases, removal of bone or soft-tissue foci, or a combination of these, in 22. The left joint was affected in 26 cases (52%) and the right in 24 (48%). The youngest patient was 9, the oldest 78 years of age (average age 42.6 years). The time from the onset of complaints to diagnosis was about 1.6 years. Twenty-eight patients (56%) had previously had treatment for tuberculosis and 9 (18%) also had active tuberculosis localized elsewhere. Even though there were clear radiological changes in all cases, abscesses and fistulae or a combination of these in 27 cases (54%), the 1-hour ESR was normal or only slightly elevated (under 20 mm acc. to W.) in 29 patients (58%). The recurrences which occurred immediately after surgery or in the subsequent course of the disease healed without sequelae after secondary interventions. While they prolonged hospitalization they did not influence the result of surgery. Of the 38 (76%) patients who were followed up on average 3 years after the end of inpatient treatment, 30 (79%) had returned to work on average 1.1 year after being discharged from the hospital. Three had meanwhile been retrained for lighter work. In the discussion the etiology and pathogenesis, incidence, side localization, age and sex distribution, complaints, clinical and radiological findings, diagnosis, therapy, prognosis, and differential diagnosis of shoulder joint tuberculosis are reported on with reference to the relevant literature.