Jay S. Cox

The Modified Bristow Procedure for Anterior Shoulder Instability 26-Year Outcomes in Naval Academy Midshipmen

Background Many procedures have been proposed for the correction of anterior shoulder instability. Some of these procedures address the problem anatomically, such as the Bankart procedure, and some prevent instability nonanatomically, such as the Bristow-Latarjet procedure. A modified Bristow procedure was the procedure of choice for anterior shoulder instability among midshipmen at the United States Naval Academy from 1975 to 1979. Hypothesis The modified Bristow procedure for anterior shoulder instability provides good shoulder function and stability in the long term. Study Design Case series; Level of evidence, 4. Methods There were 52 shoulders in 49 patients reviewed at a mean follow-up of 26.4 years. The Rowe score, Single Assessment Numeric Evaluation, and Western Ontario Shoulder Instability Index were used to assess outcomes. Results The mean Rowe score was 81.8 (range, 5-100), and the mean Single Assessment Numeric Evaluation score was 82.9 (range, 30-100), with an overall Single Assessment Numeric Evaluation of 71.2% (37 of 52 shoulders) rated as good and excellent. The mean Western Ontario Shoulder Instability Index was 376 of 2100 (range, 0-1560). Overall, recurrent instability occurred in 8 of 52 shoulders (15.4%), with recurrent dislocation in 5 shoulders (9.6%) and recurrent subluxation in 3 shoulders (5.8%). The mean time to recurrent dislocation was 7.0 years. Conclusion This study represents the longest follow-up in the literature of the modified Bristow procedure. The authors have shown nearly 70% good and excellent results and recurrent instability comparable with other long-term follow-up studies of open instability procedures.

Evaluation of the Roux-Elmslie-Trillat procedure for knee extensor realignment

One method for correction of patellofemoral malalign ment in acute and recurrent dislocations and sublux ations of the patella involves a lateral retinacular release, medial capsular reefing, and medial displace ment of the infrapatellar tendon insertion. The proce dure was originally described by Roux and later mod ified and popularized by Elmslie and Trillat. It allows adequate evaluation and easy adjustment of the ex tensor mechanism at the time of surgery. This current report is an evaluation of 116 of these procedures followed for at least one year and examined by an orthopaedic surgeon. This evaluation indicates that this is a satisfactory method for prevention of recur rent subluxation of the patella with recurrence in only 7% of the cases. A critical evaluation of the re sults of the procedure reveals only 66% were rated as good or excellent. The results were directly re lated to associated intraarticular pathology such as hemarthrosis, patellar chondromalacia, degenerative changes on the femoral or tibial articular surfaces, torn or absent semilunar cartilages, torn anterior cru ciate ligaments, and insufficient correction of either patella alta or a wide quadriceps angle. The procedure has been slightly modified and the indications for the procedure have been revised.

Twenty-six-year results after broström procedure for chronic lateral ankle instability

Background The procedure described by Broström has been used to address chronic lateral ankle instability; the long-term results of this procedure have not been reported. Hypothesis The Broström procedure provides good results over the long term for active patients with chronic lateral ankle instability. Study Design Case series; Level of evidence, 4. Methods Thirty-one male patients (32 ankles) who underwent the Broström procedure for chronic lateral ankle instability while enrolled as students at the United States Naval Academy were identified. Each patient was mailed a questionnaire that included a functional outcome measure as described by Roos et al, a score described by Good et al, and a single-number ankle functional assessment. The mean age was 20.7 years (range, 18-23 years) at the time of operation. A functional outcome score was completed on each patient, with a mean follow-up of 26.3 years (range, 24.6-27.9 years). Results The follow-up included 22 of the 31 original patients. The mean numeric score for overall ankle function was 91.2 of 100 (standard deviation, 10.2). The foot and ankle outcome score (described by Roos et al) was 92.0 (92%; standard deviation, 12.8) averaged over 5 functional areas. Ninety-one percent of the patients described their ankle function as good or excellent using the scale devised by Good et al. Conclusion The long-term results of the Broström procedure for chronic lateral ankle instability are excellent with 26-year follow-up.

The fate of the acromioclavicular joint in athletic injuries.

Of 164 acromioclavicular joint injuries to midshipmen at the US Naval Academy between July 1973 and November 1978, 99 were Type 1, 52 were Type 2, and 13 were Type 3. Follow-up examinations revealed that 36% of Type 1, 48% of Type 2, and 69% of Type 3 patients had residual symptoms. Positive physical findings were present in 43% of Type 1, 77% of Type 2, and 100% of Type 3 injuries. Roentgenographic changes were noted in 70% of Type 1, 75% of Type 2, and 100% of Type 3 patients. This evaluation suggests aggressive treatment and rehabilitation are indicated in acute acromioclavicular injuries. Residual problems from Types 1 and 2 inju ries are much more frequent than indicated in the literature. Symptoms in Type 1, but not in Type 2, injuries are directly related to the presence of positive physical findings. Roentgenographic changes are ex tremely common and are not correlated with symp toms. Treatment of Type 2 injuries with the acromio clavicular immobilizer resulted in fewer complications than symptomatic treatment.

The natural history of inadequately treated ankle sprain

for this symposium. In comparison to the knee and hip joints, the ankle joint does not seem to undergo the severe degenerative changes secondary to ligamentous instability. In a large series of ankle radiographs taken for evaluation of ankle instability, only two showed any evidence of degenerative changes. The problem, however, in inadequately treated ankle sprains is the sensation of instability in the injured ankle. In response to a questionnaire, 10% of a 1,300-man freshman class at the United States Naval Academy reported functional instability. They described this as frequent sprains, difficulty in running on uneven surfaces,

An evaluation of the Elmslie- Trillat procedure for management of patellar dislocations and subluxations: A preliminary report:

The Elmslie-Trillat procedure involves lateral retinacular release, medial capsular reefing, and medial transposition of the anterior tibial tubercle hinged on a distal periosteal attachment. It is an easily performed procedure and is an excellent method for realignment of the extensor mechanism in cases of dislocation and subluxation of the patella. In our series of 52 cases with 6-24 months postsurgical evaluation, 46 cases, or 88 percent were rated as good or excellent. It must be emphasized that this technique is used only if the epiphyseal plates are closed.

Long-Term Evaluation of the Roux-Elmslie-Trillat Procedure for Patellar Instability A 26-Year Follow-up

Background Few published articles exist reporting the long-term evaluation of the Roux-Elmslie-Trillat procedure. Purpose To assess the long-term effect of the Roux-Elmslie-Trillat procedure in preventing recurrent subluxation and dislocation of the patella. Study Design Case series; Level of evidence, 4. Methods Eighteen patients who underwent the Roux-Elmslie-Trillat procedure for dislocation or subluxation of the patella were identified from a group previously evaluated at a mean follow-up of 3 years. The prevalence of recurrent subluxation or dislocation at a mean follow-up of 26 years was compared with the prevalence reported at the mean follow-up of 3 years. Although not the focus of this study, Cox functional scores were obtained from the smaller group and compared with the results at the 3-year follow-up. Results Seven percent (95% confidence interval, 0.00-0.32) of the patients had recurrent subluxation at 26 years compared with 7% (95% confidence interval, 0.03-0.13) of the study population reported at 3 years (P = 1.00). Fifty-four percent (95% confidence interval, 0.27-0.79) rated their affected knee as good or excellent at 26 years compared with 73% (95% confidence interval, 0.64-0.81) of the larger study population reported at 3 years (P = .14). Conclusion The prevalence of recurrent subluxation and dislocation in patients with patellofemoral malalignment who underwent the Roux-Elmslie-Trillat procedure for dislocation or subluxation of the patella is similar at 3 and 26 years after the procedure. The long-term functional status of the affected knee in patients who underwent the Roux-Elmslie-Trillat procedure declined.

Women Midshipmen in Sports

This is a study of the physical performance and injury rate for seven classes of women midshipmen at the United States Naval Academy. Women comprise only 6.2% of the brigade of midshipmen, but men and women live in the same dormitory, undergo the same physical training and fitness tests, study the same academic curriculum, and live in an environment where performance and activities can be constantly moni tored. The required number of hours of physical edu cation are the same for men and women. The conclusions from this study are: (1) women midshipmen continue to improve their fitness level more rapidly than men; (2) while some disparities in perform ance are correctly attributed to physiological differ ences, many of the present disparities should be attrib uted to societal conditions; (3) should physical perform ance requirements ever become the same, women will have to work harder than men to achieve the same standards because of the physiological differences; (4) women continue to seek medical attention for stress- related problems (i.e., shin splints, stress fractures) more often than men, but do so less often as they become acclimated to the active life of the Naval Acad emy ; (5) women midshipmen have the same number of serious injuries as men, and in some sports are more susceptible to certain types of injuries.

Women in sports: the naval academy experience

Women were first admitted to the United States Naval Acad emy with the Class of 1980. The physical performance of 63 women in that class along with 69 in the Class of 1981 and 78 in the Class of 1982 is compared to the performance of a random sample of male midshipmen in the same Classes. The Department of Physical Education made some adjustments in the fitness program for women but did not change the objec tives. The number of hours of physical education was the same for the men and women. Performance tests show that the women have scored better than had been anticipated and that the scores have improved with each Class. The women have averaged three times as many visits to the orthopaedic clinic for stress-related injuries than the men, but as the women have become acclimated to a more active life, they have sought medical attention for these problems less often. The women in these three Classes have had no trauma-related orthopaedic surgery. It is anticipated that when women midshipmen begin to participate in the same vigorous sports as men, e.g., soccer, lacrosse, and others, that injuries will increase. We conclude that physical fitness requirements for women will become in creasingly similar to the mens requirements. At this time, the performance of women is often a result of societys conditioning rather than apparent physiologic differences between the sexes.

Use of phenylbutazone in sports medicine: understanding the risks

Despite the widespread use of phenylbutazone, its safety is still a controversial issue. One example of its toxicity is the fact that phenylbutazone has now replaced chloramphenicol as the most common cause of fatal drug-related aplastic anemia. To evaluate the toxicity of phenylbutazone as it is commonly used in sports medicine, a group of 3,000 healthy young athletes was studied following 1-week courses of phenylbutazone for various sports-related inflammatory problems. No serious adverse re actions were encountered. Four percent of the patients expe rienced mild gastrointestinal disturbances with less than 1% of the patients being forced to discontinue the medication. Com piling the results of other studies, it is estimated that the risk of a serious reaction to phenylbutazone is less than 1 per 100,000 when the drug is used by healthy young individuals for periods of 1 week or less. This risk increases significantly in older patients and with longer periods of treatment. Although phenylbutazone is widely prescribed in sports medicine, there appears to be insufficient information regarding its possible effects on athletic performance. Its capacity to cause significant fluid retention with secondary dilutional anemia, for example, could, in certain instances, have an adverse effect on overall performance if the drug is continued after the athlete returns to competition. Further study in this area is urged.