Carter R. Rowe

Recurrent transient subluxation of the shoulder.

We studied thirty-three normal pa tients, eighteen women and fifteen men, for normal motion and the amount of elbow motion required for fifteen activities of daily living. The amounts of elbow fiexion and forearm rotation (pronation and supina tion) were measured simultaneously by means of an electrogoniometer. Activities of dressing and hygiene require elbow positioning from about 140 degrees of fiexion needed to reach the occiput to 15 degrees of flex ion required to tie a shoe. Most of these activities are performed with the forearm in zero to SO degrees of supination. Other activities of daily living (such as eat ing, using a telephone, or opening a door) are accom plished with arcs of motion of varying magnitudes. Most of the activities of daily living that were studied in this project can be accomplished with 100 degrees of elbow flexion (from 30 to 130 degrees) and 100 degrees of forearm rotation (50 degrees of prona tion and 50 degrees of supination). CLINICAL RELEVANCE: These data, not previously recorded, may be used to provide an objective basis for the determination of disability impairment, to deter mine the optimum position for elbow splinting or ar throdesis, and to assist in the design of elbow pros theses. The motion needed to perform essential daily activities is obtainable with a successful total elbow ar

Prognosis in Dislocations of the Shoulder

1. Five hundred shoulders in a series of 488 patients, with a follow-up study on 313 shoulders (63 per cent), are reviewed relative to prognosis. 2. The study included patients treated over the past twenty years, with a mean follow-up period of 4.8 years. 3. In 38 per cent of the patients the dislocation recurred. 4. Primary shoulder dislocations were found to occur as frequently after forty-five years of age as before forty-five. 5. The incidence of recurrent dislocation of the shoulder was very high in the second decade (92 per cent), but showed marked decrease after age fifty (12 per cent). 6. The age of the patient at the time of the primary shoulder dislocation was the most significant single prognostic factor. 7. Throughout this study, the average age of those patients in whom redislocation did not occur was greater than in those in whom dislocation did recur. 8. Various phases of trauma in relation to dislocations were reviewed. Usually the greater the initial injury, the lower was the incidence of recurrence. 9. Fracture of the shoulder girdle was a complication in 24 per cent. The incidence of fracture of the greater tuberosity was 15 per cent. This complication was accompanied by an appreciable lowering of the incidence of recurrence (7 per cent). The exception was in chip fractures of the anterior glenoid rim. 10. Humeral-head defects were present in 38 per cent of the primary dislocations and in 57 per cent of recurrent dislocations. These were associated with an increase in the incidence of recurrence (82 per cent). 11. From our figures, the incidence of recurrence seemed to be affectd very little by the type and length of immobilization of the shoulder following dislocation. Although a high incidence of recurrence was noted in the group of patients for whom where was no immobilization or for whom there were very short periods of immobilization, long periods of immobilization were not associated with a significant decrease in recurrence. 12. The incidence of recurrent dislocation relative to handedness was not significant. 13. Following primary or initial dislocation, 70 per cent of the dislocations which recurred did so within two years. 14. Following operative procedures for the repair of recurrent shoulder dislocation, 52 per cent recurred within two years after operation. 15. The incidence of posterior dislocation was 2 per cent. 16. The incidence of bilateral dislocation was 2.4 per cent. 17. The incidence of associated nerve injury was 5.4 per cent. 18. The incidence of epileptics with shoulder dislocations was 2 per cent.

Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment.

We analyzed the cases of thirty-nine patients who were treated for recurrent anterior dislocation of the shoulder after unsuccessful surgical repair for the same condition in order to identify factors responsible for failure of the earlier operations and to determine the results of treatment of the post-surgical recurrence. The prior operations included nineteen Bankart, seven Putti-Platt, five Magnuson, three duToit, two Bristow, and three Nicola procedures. Thirty-two shoulders were treated by reoperation. At reoperation the most common pathological lesion associated with recurrence of the dislocation after the prior repair was a Bankart lesion (avulsion of the capsule and labrum from the anterior glenoid rim). This was present in 84 per cent of the thirty-two shoulders that were treated by reoperation. Excessive laxity of the capsule was found in 83 per cent of the twenty-nine shoulders in which laxity was assessed, and was considered to be the primary cause of instability in four shoulders. A Hill-Sachs lesion of the humeral head was found in 76 per cent of the twenty-nine shoulders that were evaluated for this lesion and was large in three of the shoulders. Other factors that were associated with recurrent instability were scarring of the subscapularis muscle, generalized ligament laxity, technical errors at surgery, and severe reinjury. The success rate of reoperation after previous failure was very encouraging. Of the twenty-four shoulders that were reoperated on and were followed for two years or longer, ten were graded excellent; twelve, good; and two, poor. One (4 per cent) of the twenty-four shoulders that were reoperated on continued to dislocate and another shoulder continued to subluxate, making the incidence of recurrent instability after reoperation 8 per cent. Seven of the thirty-nine shoulders did not have a reoperation but were treated with specific resistive exercises. The results in these were one excellent, four good, one fair, and one poor. Eight patients were lost to follow-up.

Chronic unreduced dislocations of the shoulder.

We evaluated the results of treatment in twenty-three patients with twenty-four shoulder dislocations that had gone unreduced for at least three weeks. Fourteen dislocations were posterior, eight were anterior, and one each was superior and inferior. Seventy-nine per cent of the posterior dislocations had not been recognized by the initial treating physician. Fourteen shoulders (58 per cent) were operated on. Of seven that were treated by open reduction with preservation of the humeral head, the results in two were graded as excellent; in three, as good; and in two, as fair. A Neer total shoulder-replacement prosthesis was used in one patient with an excellent result, and a Neer humeral-head prosthesis was used in two patients with a good and a fair result. In four patients, the humeral head was removed and a Jones procedure was performed, with one good and three fair results. There were no poor results after surgical treatment and it was not necessary to arthrodese any shoulder. We did not find it necessary to transfix the shoulder joint by screws or pins, or to use plaster spica casts to maintain stability of the shoulder following open reduction. Supporting the arm at the side in a position posterior to the coronal plane for a posterior dislocation, and anterior to the coronal plane for an anterior dislocation, proved to be comfortable and effective. There were no postoperative dislocations using this simple method. These results show that the over-all prognosis for surgical treatment of the chronic unreduced dislocation shoulder is more favorable than has previously been reported. A rating system based on 100 units was used to evaluate our final results, and is recommended as a standard system for future comparative studies.

Combined anterior cruciate-ligament reconstruction using semitendinosus tendon and iliotibial tract.

We are reporting the results of a reconstructive procedure designed to decrease anterior tibial subluxation due to disruption of the anterior cruciate ligament. The operation combines both intra-articular and extra-articular methods. The semitendinosus tendon and the iliotibial tract are both routed from opposite directions over the top of the lateral femoral condyle and through the same oblique drill-hole in the proximal part of the tibia: the semitendinosus tendon is passed up through the tibial drill-hole, across the knee joint, over the top of the lateral femoral condyle, and deep to the fibular collateral ligament, and the iliotibial tract is passed deep to the fibular collateral ligament, over the top of the lateral femoral condyle, across the knee joint, and down through the drill-hole. Both grafts are simultaneously pulled tight while the semitendinosus tendon is sutured to the iliotibial tract laterally and the iliotibial tract is sutured to the semitendinosus tendon medially below the drill-hole. The posteromedial and lateral parts of the capsule are advanced to tighten the secondary restraints. One hundred of the first 106 consecutive patients with chronic instability who had this procedure were evaluated using subjective and objective criteria at three to seven and one-half years after surgery. The positive anterior-drawer sign tested at 25 degrees of flexion was eliminated or reduced to 1+ in eighty knees, and the positive pivot shift was reduced to zero or 1+ in ninety-one knees. The objective assessment of isokinetic muscle performance and passive tibial rotation showed significant improvements in strength and normalization of tibial rotation.

Voluntary Dislocation of the Shoulder: A Preliminary Report On A Clinical, Electromyographic, And Psychiatric Study Of Twenty-six Patients

Clinical, roentgenographic, electromyographic, and psychiatric studies of twenty-six patients with voluntary dislocation of one or both shoulders revealed that dislocation was produced by suppression of one element of one of the muscle force-couples responsible for normal shoulder motion, that most patients responded well to muscle-strengthening exercises, that patients with significant psychiatric problems did poorly after all types of surgical and non-operative treatment unless their psychiatric problem had been resolved, and that if surgical treatment was undertaken, a combination of procedures was necessary rather than one of the standard operations.

Prognosis of Fractures of the Acetabulum

An end-result study of ninety-three acetabular fractures in ninety patients followed for from one to twenty-seven years, or for an average of six years, is presented. These fractures were classified as undisplaced, posterior, inner-wall, and superior or bursting fractures. The prognosis would be different in the different types of fracture, but, in general, the prognosis was found to be more favorable than would be anticipated from current reports in the literature. The more favorable outlook for this fracture derived from this study is perhaps due to the fact that the patients studied were all those whose initial treatment was in one hospital. This gave a more representative balance between the good and poor results. The outcome of the hip appeared to depend primarily on the condition of the dome or weight-bearing portion of the acetabulum, the condition of the femoral head, the adequacy of the reduction of the dislocation, and the stability of the joint after treatment. The clinical and roentgenographic findings in the affected hips one year after injury were found to be a most reliable guide to the ultimate prognosis of the hip, since definite changes were noted at one year in those hips that deteriorated.

Rotational motion of the knee

This study deals with the quantitation of axial rotation at the knee. Passive rotation of the knee was measured at various degrees of flexion on 17 subjects with normal knees and 19 patients with unilateral anterolateral ro tatory instability. Normal subjects were found to have bilateral sym metric rotational knee motion at each angle of flexion tested. When the knee is in a position of flexion be tween 30 and 90°, there are approximately 45° external and 25° internal rotation. Rotatory motion decreases with further extension and, at 5° of flexion, the knee has 23° external and 10° internal rotation. The knee with a torn anterior cruciate ligament and anterolateral rotatory instability was found to have an arc of rotation similar to the contralateral knee and to the control knees between 30 and 90° flexion. At 15° of flexion, a slightly greater arc of rotation was meas ured compared to normal knees. At 5° of flexion, a significantly greater range of external (to 41 °) as well as internal (to 14°) rotation was measured.

Diagnosis and treatment of traumatic anterior instability of the shoulder.

Traumatic anterior glenohumeral joint dislocation is the most common type of shoulder instability. Lesions that usually result are avulsion of the anterior capsule and glenoid labrum from the glenoid rim (Bankart lesion), compression fracture of the posterosuperior humeral head (Hill-Sachs lesion), and laxity of the joint capsule. Another common lesion is a lengthwise disruption of the rotator cuff at the interval between the subcapularis and supraspinatus tendons. The shoulder that dislocates repeatedly after trauma has an excellent success rate when treated by surgical repair. The aim of the Bankart procedure is to restore stability to the shoulder by repairing the traumatic lesion of the anterior glenoid rim without altering normal anatomy.

Re-Evaluation of the Position of the Arm in Arthrodesis of the Shoulder in the Adult

Based on a study of eight patients with arthrodesis of the shoulder and on a review of the literature, it was concluded that the amount of abduction usually recommended is excessive for adults in whom internal fixation is used. The position should be determined with the arm at the side of the body with enough clinically determined abduction of the arm from the side of the body (15 to 20 degrees) to clear the axilla and enough forward flexion (25 to 30 degrees) and internal rotation (40 to 50 degrees) to bring the hand to the mid-line of the body, the face and head, the side and pants pockets, the back, the anal region, and the feet. When arthrodesed in this position the arm will rest comfortably at the side, and the scapula will not protrude. The arm will also be nearer the center of gravity of the body, the position where strength is maximum for lifting, pushing, and pulling. However, if there is paralysis of the muscles of the shoulder girdle and arm, the position should be adjusted according to the specific muscle weakness.