Gary S. Perlmutter

Stability of Acromioclavicular Joint Reconstruction Biomechanical Testing of Various Surgical Techniques in a Cadaveric Model

Background Despite reports of excellent results with the Weaver-Dunn coracoacromial ligament transfer, many authors recommend augmenting the transfer with supplemental fixation. The authors of this study sought to determine whether there is a biomechanical basis for this assertion and which augmentative method, if any, most closely restored acromioclavicular motion to normal. Hypothesis Augmentative coracoclavicular fixation provides better restoration of normal acromioclavicular joint laxity and an increased failure load when compared with the Weaver-Dunn reconstruction alone. Study Design Controlled laboratory cadaveric study. Methods Native acromioclavicular joint motion was measured using an infrared optical measurement system. Acromioclavicular and coracoclavicular ligaments were then cut, and 1 of 6 reconstructions was performed: Weaver-Dunn, suture cerclage, and 4 different suture anchors. Acromioclavicular joint motion was reassessed, a cyclic loading test was performed, and the failure load was recorded. Results After Weaver-Dunn reconstruction, mean anteroposterior laxity increased from 8.8 ± 2.9 mm in the native state to 41.9 ± 7.6 mm (P≤ .01), and mean superior laxity increased from 3.1 ± 1.5 mm to 13.6 ± 4.4 mm (P≤ .01). Weaver-Dunn reconstructions failed at a lower load (177 ± 9 N) than all other reconstructions (range, 278-369 N) (P≤ .05). Reconstruction using augmentative fixation allowed less acromioclavicular motion than Weaver-Dunn reconstruction (P≤ .05) but more motion than the native ligaments (P≤ .05). Specifically, mean superior laxity after reconstruction ranged between 6.5 and 9.0 mm compared with the native ligaments (3.1 ± 1.5 mm) and the Weaver-Dunn reconstructions (13.6 ± 4.4 mm). Mean anteroposterior laxity after the reconstructions tested ranged between 21.8 and 33.2 mm, compared with the native ligaments (8.8 ± 2.9 mm) and the Weaver-Dunn reconstructions (41.9 ± 7.6 mm). Conclusion Although none of the augmentative methods tested restored acromioclavicular stability to normal, all proved superior to the Weaver-Dunn reconstruction alone. Clinical Relevance This study suggests that when performing acromioclavicular reconstruction, supplemental fixation should be used because it provides more stability and pull-out strength than the Weaver-Dunn reconstruction alone.

Axillary nerve injury.

Axillary nerve injury remains the most common peripheral nerve injury to affect the shoulder. It most often is seen after glenohumeral joint dislocation, proximal humerus fracture, or a direct blow to the deltoid muscle. Compression neuropathy has been reported to occur in the quadrilateral space syndrome, although the true pathophysiology of this disorder remains unclear. The axillary nerve is vulnerable during any operative procedure involving the inferior aspect of the shoulder and iatrogenic injury remains a serious complication of shoulder surgery. During the acute phase of injury, the shoulder should be rested, and when clinically indicated, a patient should undergo an extensive rehabilitation program emphasizing range of motion and strengthening of the shoulder girdle muscles. If no axillary nerve recovery is observed by 3 to 6 months after injury, surgical exploration may be indicated, especially if the mechanism of injury is consistent with nerve rupture. Patients who sustain injury to the axillary nerve have a variable prognosis for nerve recovery although return of function of the involved shoulder typically is good to excellent, depending on associated ligamentous or bony injury.

Results of transfer of the pectoralis major tendon to treat paralysis of the serratus anterior muscle

BACKGROUND Paralysis of the serratus anterior muscle can be functionally disabling. As a result of the scapular winging associated with such paralysis, the scapula does not remain apposed to the thorax when the upper extremity is elevated forward at the shoulder. This produces functional disability associated with pain and loss of a stable base for movement of the upper extremity. METHODS We reviewed the results of transfer of the pectoralis major tendon with the addition of a fascial graft in sixteen patients who had paralysis of the serratus anterior. The average age of the patients at the time of the operation was thirty-three years (range, twenty to fifty-five years). Electrodiagnostic studies confirmed the presence of an isolated injury of the long thoracic nerve. The index operation was performed sixteen months to eleven years after the onset of pain and weakness. The etiology of the paralysis was idiopathic in two patients, traumatic in seven, and secondary to operative intervention in seven. All patients had pain in the shoulder on the side of the paralysis. RESULTS The result was excellent for eight patients, good for five, and fair for one at an average of four years and three months (range, two years and one month to nine years) postoperatively. There were two failures, both of which occurred after a traumatic event. Of the fourteen patients in whom the procedure did not fail, eight were asymptomatic and had normal function, five had intermittent mild discomfort, and one had frequent mild pain without any winging of the scapula. The average Constant and Murley score for the fourteen patients in whom the procedure did not fail increased from 36 points preoperatively to 92 points postoperatively. CONCLUSIONS The index procedure successfully alleviated the functional disability caused by paralysis of the serratus anterior muscle.

Thoracic outlet syndrome. Results of 282 transaxillary first rib resections.

Thoracic outlet syndrome may follow trauma but also may be seen as a result of postural abnormalities of the shoulder girdle. Cervical ribs and other anatomic variations are not prerequisites for the diagnosis, although they may be more common in patients with thoracic outlet syndrome. The diagnosis is made by history and physical examination. There is no reliable laboratory diagnostic test to confirm or exclude the diagnosis. Proper selection of candidates for surgery can produce excellent and good results in a high percentage of cases. The transaxillary approach to first rib resection is tolerated well, and serious complications should be unusual when the procedure is performed by an experienced surgeon. Postoperative attention to shoulder girdle mechanics is important in the prevention of recurrence of symptoms and treating them should they occur.

Axillary nerve injuries in contact sports: recommendations for treatment and rehabilitation.

Axillary nerve injuries are some of the most common peripheral nerve injuries in athletes who participate in contact sports. Resulting deltoid muscle paralysis is secondary to nerve trauma which occurs following shoulder dislocation or a direct blow to the deltoid muscle. Compression neuropathy has been reported to occur in quadrilateral space syndrome as the axillary nerve exits this anatomic compartment. The axillary nerve is also extremely vulnerable during any operative procedure involving the inferior aspect of the shoulder, and iatrogenic injury to the axillary nerve remains a serious complication of shoulder surgery. Accurate diagnosis of axillary nerve injury is based on a careful history and physical examination as well as an understanding of the anatomy of the shoulder and the axillary nerve in particular. Inspection, palpation and neurological testing provide the bases for diagnosis. A clinically suspected axillary nerve injury should be confirmed by electrophysiological testing, including electromyography and nerve conduction studies.During the acute phase of injury, the athlete should be rested and any ligamentous or bony injury should be treated as indicated. Patients should undergo an extensive rehabilitation programme emphasising active and passive range of motion as well as strengthening of the rotator cuff, deltoid and periscapular musculature. Shoulder joint contracture should be avoided at all costs as a loss of shoulder mobility may ultimately affect functional outcome despite a return of axillary nerve function. If no axillary nerve recovery is observed by 3 to 4 months following injury, surgical exploration is indicated.Athletes who sustain injury to the axillary nerve have a variable prognosis for nerve recovery, although the return of function of the involved shoulder is typically good to excellent. We recommend that athletes who sustain axillary nerve injury may return to contact sport participation when they achieve full active range of motion of the shoulder and when shoulder strength is documented to be good to excellent by isometric or manual muscle testing.

Direct Injury to the Axillary Nerve in Athletes Playing Contact Sports

We performed long-term followup (31 to 276 months) of 11 contact athletes who had sustained isolated in juries to their axillary nerves during athletic competi tion. There were no known shoulder dislocations. Elec tromyographs were taken of 10 patients, and all patients had confirmation of clinically defined injuries that were confined to their axillary nerves. Nine injuries were sustained while tackling opposing players in foot ball ; two were sustained in hockey collisions. In seven athletes, the mechanism of injury was a direct blow to the anterior lateral deltoid muscle. In four athletes, there were simultaneous contralateral neck flexion and ipsilateral shoulder depression. At followup, all patients had residual deficits of axillary sensory and motor nerve function. There had been no deltoid muscle im provement in three patients, moderate improvement in two patients, and major improvement in six patients. However, shoulder function remained excellent, with all athletes maintaining full range of motion and good- to-excellent motor strength. Axillary nerve exploration and neurolysis in four patients did not significantly affect the outcomes. Although no patient had full re covery of axillary nerve function, 10 of 11 athletes returned to their preinjury levels of sports activities, including professional athletics.

Transient compartment syndrome of the forearm after attempted radial artery cannulation

Radial artery cannulation for continuous intraoperative monitoring of arterial blood pressure is considered a safe procedure. One complication of arterial cannulation is hematoma formation at the time of insertion or removal of the catheter. Bleeding is usually self-limited or will stop with compression without significant sequelae, even in the anticoagulated patient. We describe a case of hematoma with a transient compartment syndrome of the forearm after attempts to cannulate the radial artery for intraoperative monitoring purposes.