G. William Woods

Little League survey: the Houston study

1. In a study of 595 Little League pitchers, approximately 17% had a history of elbow symptoms: only 1% had elbow symptoms which had ever excluded them from pitching. There was no correlation between the presence of symptoms and years of pitching experience. 2. Some limitation of active extension of the elbow was seen in 12% of the pitchers; however, there was no correlation between elbow flexion contractures and years of pitching experience, symptoms, or roentgenographic pathology. No normal child had an elbow flexion contracture greater than 15 degrees. 3. A slight valgus carrying angle is considered a normal anatomic variant in the dominant arm. There was no correlation between valgus carrying angle and years of pitching experience or symptoms or roentgenographic pathology. 4. No roentgenographic evidence of avascular necrosis of the capitellum, radial head, or both was seen in this population. 5. Roentgenographic findings such as bony hypertrophy, enlargement of the medial epicondyle, and secondary ossification centers are normal anatomic variants not related to symptoms. Undisplaced stress fractures of the medial epicondyle respond well to conservative treatment, with no functional residual.

Elbow instability and medial epicondyle fractures.

For years, satisfactory results have been achieved with nonoperative management of fractures of the medial epicondyle of the humerus. Traditionally, open reduction has been reserved for those cases in which the fragment is trapped within the joint, or when displacement of the medial epicondyle by x-ray exceeds some arbitary figure, usually 1.0 cm. In most patients, fractures with only minimal displacement heal rapidly by bony union in a splint. Elbow range of motion is regained rapidly. In the sedentary patient with more than minimal displacement, nonoperative treatment can still yield a satisfactory elbow, although intermittent symptoms and loss of a few degrees of extension are not unusual. Fibrous rather than

Lateral capsular sign: x-ray clue to a significant knee instability

The purpose of this presentation is to describe a simple radiographic finding, visible on the routine anteroposterior knee x-ray, which indicates severe lateral capsular injury and should alert the examiner to the high probability of anterior cruciate and medial ligamentous damage. Basic capsular anatomy is reviewed first, then the lesion itself is described in detail. Two cases are presented, one which

Patellar pain and quadriceps rehabilitation An EMG study

Eighteen patients (26 knees) giving a history of patel lar dislocation and/or subluxation and continued pa tellar symptoms underwent evaluation to determine the efficacy of their rehabilitation programs. Four- channel cine-electromyography was utilized to assess the relative muscular effort of the vastus medialis, vastus lateralis, vastus medialis obliquus, and rectus femoris in a series of exercises. Ten degress of flexion of the knee reduced effective muscle effort in the vasti group to an average of ¼ of the muscle effort dem onstrated in full extension of the knee. No consistent pattern was noted by altering the rotation of the hip from neutral to external or internal rotation. The ad dition of weight (5 Ib) to the ankle did not enhance the muscle effort with the knee in full extension. Quad- sets and straight leg-raising exercises in full knee extension offer the best quadriceps rehabilitation pro gram in the patient with a patellar malalignment syn drome and persistent symptoms.

Arthroscopic management of lateral meniscal cysts

This study presents seven cases of lateral meniscal cysts treated arthroscopically. All were noted to have meniscal lesions at the time of surgery; there were five flap tears and two radial tears. Partial arthroscopic meniscectomy was performed and the contents of the cysts were manipulated into the joint in six of seven cases. One patient underwent open cyst excision in addition to partial arthroscopic meniscectomy. Fol lowup ranged from 18 months to 4 years with an average of 28 months. There were no cyst recurrences. The pathologic basis of the meniscal cyst is controver sial, but recent work suggests the etiology is infiltration of joint fluid through micro and macro tears in the meniscus. Partial meniscectomy retains valuable men iscal function while minimizing the likelihood of cyst reformation. We found arthroscopic partial meniscec tomy with manipulation of the contents of the cyst into the joint to be a successful alternative to complete open meniscectomy.

Repairable posterior menisco-capsular disruption in anterior cruciate ligament injuries

Two hundred thirty-four consecutive patients with a positive Lachman test underwent examination under anesthesia and diagnostic arthroscopy to include com plete evaluation of both posterior menisco-capsular attachments. Knees which had had previous arthrot omy were excluded. Complete repairable posterior menisco-capsular dis ruptions occurred in 31 of 112 (27.7%) acute cases and 36 of 122 (29.5%) knees in the chronic group. These lesions are not predictable by physical exami nation or by routine clinical grading of instability. Thor ough arthroscopic examination to include direct visual ization of the posterior menisco-capsular junction is necessary for complete diagnosis in anterior cruciate ligament injuries.

Proplast leader for use in cruciate ligament reconstruction

A synthetic leader has been used in 18 cases of medial one- third patellar tendon substitution for the anterior cruciate ligament and in 10 cases of posterior cruciate substitution using the medial head of the gastrocnemius tendon. The device adds length and facilitates manipulation of the transplanted tissues. There have been no problems with biocompatibility and there have been no instances of staple loosening or disruption of the junction between the stabilizer and transplanted tissues. Early results with the anterior cruciate substitutions suggest that anchoring the transfer in bony tunnels in both the tibia and femur does not allow sufficient flexibility to prevent stretching or disruption of the tendon transfer.

Orthopaedic surgeons do not increase surgical volume after investing in a specialty hospital

BACKGROUND The number of surgical specialty hospitals with physician investors in the United States has increased in the last ten years. Opponents to these hospitals have argued that surgeon investors will perform more surgery in order to maintain the hospitals profitability. The purpose of the present study was to determine whether the surgical volume or the surgical rate increased for a group of ten orthopaedic surgeons after the opening of an orthopaedic surgery specialty hospital in which they held a financial interest. METHODS We analyzed the practice data for ten orthopaedic surgeons during an interval spanning seven years before and eight years after the opening of an orthopaedic surgery specialty hospital in which they held a financial interest. The average rates of change in the number of surgical procedures per year for each period were computed and compared with use of regression analysis. The percentages of patients who underwent surgery before and after the opening of the specialty hospital were also compared. RESULTS The ten orthopaedic surgeons did not increase their surgical volume or surgical rate after the specialty hospital opened. The ten surgeons performed an average of 4399 surgical procedures per year before the hospital opened and 4542 surgical procedures per year after the hospital opened. The rate of change in the number of surgical procedures per year (19.1 compared with 8.9 procedures per year) did not increase after the specialty hospital opened. The annual patient volume (16,019 compared with 15,982 patients) and the percentage of patients who underwent surgery (27.5% compared with 28.4%) did not significantly change after the specialty hospital opened. CONCLUSIONS The opening of an orthopaedic surgery specialty hospital did not increase the surgical volume or the surgical rate for ten orthopaedic surgeons who held a financial interest in the facility.

Intra-articular morphine versus bupivacaine for postoperative pain management.

The purpose of this study was to determine whether morphine would be as effective as bupivacaine for postoperative pain control after knee arthroscopy with no worsening of the side effect profile. Eighty-two patients who underwent partial meniscectomy, chondral debridement, or both were prospectively randomized to receive 10 mg of morphine (10-cc volume) or 10 cc of .5% bupivacaine immediately postoperatively. Visual analog scale scores and side effect profiles were recorded in the postanesthesia care unit, in the transitional care unit, and then every 4 hours postoperatively until 24 hours. In-hospital data were available for all 82 patients, but postdischarge data were available for only 64 patients. Visual analog scale scores in the postanesthesia care unit decreased from 3.4 on admission to 2.4 on discharge for the morphine group and from 2.6 to 2.4 for the bupivacaine group (P>.217, all time points). Medication use was the same for both groups in the hospital (62% and 78%, respectively) with no statistical difference. Visual analog scale scores decreased from 3.0 to 1.5 for the morphine group and from 2.8 to 1.8 for the bupivacaine group between 4 and 24 hours postoperatively (P>.376, all time points). Medication use decreased between 4 and 24 hours postoperatively for both groups, from 71.7% to 52.9%, respectively, with no statistical difference at all time points. Four patients in the morphine group and 1 patient in the bupivacaine group experienced side effects. This study indicates that 10 mg of intra-articular morphine is as effective as 10 cc of .5% bupivacaine for postoperative pain control for partial meniscectomy and chondral debridement of the knee. It minimally increases side effects initially and circumvents the issue of chondral toxicity of bupivacaine.

A biomechanical evaluation of the iliotibial tract screw tenodesis

Biomechanical testing of the iliotibial tract screw teno desis was performed in 10 cadaveric knees under forces approximating in vivo conditions. Force versus displacement curves at various flexion angles were generated with the anterior cruciate ligament intact, with the anterior cruciate ligament sectioned, and after the iliotibial tract screw tenodesis had been performed. Displacement force was measured to 5, 10, and 15 mm. The iliotibial tract screw tenodesis was ineffective in reducing anterior translation of the tibia in the anterior cruciate ligament-deficient knee at forces approximat ing in vivo conditions.