Otto Sneppen

Lateral collateral ligament of the elbow joint: Anatomy and kinematics*

The structure and kinematics of the lateral collateral ligament of the elbow joint were investigated in 10 cadaveric specimens. The lateral collateral ligament was observed to be a distinct part of the lateral collateral ligament complex. It contains posterior fibers that pass through the annular ligament and insert on the ulna. Three-dimensional kinematic measurements in different forearm rotations showed that joint puncture induced a 1 degree joint laxity significant in forced varus from 30 degrees to 80 degrees of flexion and in forced external rotation from 30 degrees to 120 degrees of flexion. Division of the posterolateral capsule caused no further laxity. Cutting the lateral collateral ligament induced a maximum laxity of 11.8 degrees at 110 degrees of flexion in forced varus and a maximum laxity of 20.6 degrees at 110 degrees of flexion in forced external rotation. The corresponding maximal posterior radial head translation was observed at 80 degrees to 100 degrees of flexion and was 5.7 mm in forced varus and 8.1 mm in forced external rotation. This study suggests the lateral collateral ligament to be an important stabilizer of the humeroulnar joint and the radial head in forced varus and external rotation. The humeroulnar stability is independent of forearm rotation.

Total shoulder replacement in rheumatoid arthritis: Proximal migration and loosening

A prospective study of 62 Neer mark II total shoulder arthroplasties performed during the period from 1981 to 1990 on 51 patients with rheumatoid arthritis was undertaken to evaluate factors associated with component loosening and proximal humeral migration. Thirty-two (51%) showed proximal migration of the humerus before surgery was performed. The mean follow-up time was 92 months (range 52 to 139 months). The results revealed proximal migration in 55% of the patients (34 shoulders), and 40% (25 shoulders) showed progressive radiographic loosening of the glenoid component. Five of 12 press-fit humeral components demonstrated progressive radiographic loosening, whereas no signs of loosening were found in 50 cemented humeral components. In spite of progressive component loosening and progressive migration, this study demonstrated good pain relief in 89% of the patients (55 shoulders) and also a significant improvement in range of movement and function. The presence of proximal humeral migration did not significantly influence the average results-neither pain relief, range of movement, abduction force, nor function. Also, component loosening did not significantly influence the average pain relief, range of movement, abduction force, or function. The risk of clinical asymptomatic loosening is a relatively late complication that is eventually followed by pronounced bone destruction related to the loose component. Long-term radiographic control of total shoulders with rheumatoid arthritis is recommended. Hemiarthroplasty with a cemented humeral prosthesis may be a better treatment in the end stage of rheumatoid arthritis of the shoulder.

Kinematics of the lateral ligamentous constraints of the elbow joint

Thirty osteoligamentous elbow joint specimens were included in a study of the lateral collateral ligament complex (LCLC). The morphologic characteristics of the LCLC were examined, and then three-dimensional kinematic measurements were undertaken after selective ligament dissections were performed. Isolated sectioning of the annular ligament (AL) or the lateral ulnar collateral ligament (LUCL) induced only minor laxity to the elbow joint with a maximum of 2.2 degrees and 4.4 degrees during forced varus and external rotation (supination), respectively. Transsection of the lateral collateral ligament (LCL) caused a maximal laxity of 15.4 degrees and 22.8 degrees during forced varus and external rotation (supination), respectively. Combined ligament dissections showed that total transection of the LCLC at the ulnar or the humeral insertion was important for joint laxity. Total transection of the LCLC at the humeral or the ulnar insertion induced a maximal laxity of 24.5 degrees and 37 degrees during forced varus and external rotation (supination), respectively. This study suggests the AL and the LUCL are of minor importance as constraints when cut separately, whereas the LCL is a significant preventer of elbow joint laxity. The LCLC was observed to be a complex structure of ligamentous fibers rather than discreet bands. The LCLC forms a ligamentous constraint between the lateral humeral epicondyle and the ulna, stabilizing the elbow joint and forming a base for radial head stability and rotation.

Functional and magnetic resonance imaging evaluation after single-tendon rotator cuff reconstruction

The aim of this study was to investigate tendon integrity after surgical repair of single-tendon rotator cuff lesions. In 31 patients, 31 single-tendon repairs were evaluated. Thirty-one patients were available for clinical assessment and magnetic resonance imaging (MRI) at follow-up. A standard series of MR images was obtained for each. The results of functional assessment were scored according to the system of Constant. According to MRI evaluation, 21 (68%) patients had an intact or thinned rotator cuff and 10 (32%) had recurrence of a full-thickness cuff defect at follow-up. Patients with an intact or thinned rotator cuff had a median Constant score of 75.5 points; patients with a full-thickness cuff defect had a median score of 62 points. There was no correlation between tendon integrity on postoperative MR images and functional outcome. Patients with intact or thinned cuffs did not have significantly better functional results than patients with retorn cuffs. Because of the presence of metal artifacts and the difficulty in distinguishing postoperative scar tissue from partial tears or thinning, MRI is of minor diagnostic value in assessing the shoulder after cuff repair. However, full-thickness tears are readily diagnosed after operation with MRI.

Frozen shoulder: Arthroscopy and manipulation under general anesthesia and early passive motion

During a 15-month period, 24 patients with arthroscopically verified frozen shoulders were treated with manipulation while under general anesthesia and early passive motion. The minimum follow-up was 12 months, and the average duration from onset of the disease until treatment was 8 months. All patients had moderate to severe pain, and the average range of motion was less than 40% of the opposite shoulder. During the follow-up period, 75% of the patients obtained normal or almost full range of motion, and 79% had slight pain or no pain at all. Eighteen (75%) patients returned to work 9 weeks (mean) after treatment. There was no relationship between the end result and the initial pathologic condition. We believe that manipulation combined with arthroscopy is an effective way of shortening the course of an apparently self-limiting disease and should be considered when conservative treatment has failed.

Shoulder arthroplasty in complex acute and chronic proximal humeral fractures.

From 1983 to 1988, 42 shoulder arthroplasties were performed on comminuted acute or chronic proximal humeral fractures. Patients were categorized according to the post-fracture operative delay; there were 15 four-part fractures, with median post-fracture delay of 13 days (range: 7 to 21), and 27 chronic fractures, including 11 four-part fractures, 9 three-part fractures, and 7 two-part fractures, with median post-fracture delay of 14 months (range: 4 to 72). Follow up was approximately 2 years in both groups (range: 1 to 5). All patients were evaluated according to a modified Neer score-system and classified into four groups. Pain relief was satisfactory in the acute group, but was unpredictable in the chronic group. The results in the acute group were significantly superior (P less than .05). In the acute group, 3 (20%) patients had an excellent result and 6 patients (40%) had a good result, compared to a good result obtained by 6 patients (22%) in the chronic group. Two patients (13%) in the acute group and 11 patients (40%) in the chronic group had a poor result. There were no statistical differences between two-part, three-part, or four-part fractures in the chronic group. Five cases of persistent instability were seen in shoulders formerly treated with osteosynthesis (one acute and four chronic cases). Two of these cases developed an infection. Good results can be expected after prosthetic replacement in acute proximal humeral fractures. Failed primary treatment reduces the possibility of a good result with revision arthroplasty.

Heterotopic bone formation following total shoulder arthroplasty

The incidence and location of heterotopic bone formation following total shoulder arthroplasty were evaluated in 58 Neer Mark-II total shoulder replacements. One year after surgery, 45% had developed some ectopic ossification. In six shoulders (10%) the ossifications roentgenographically bridged the glenohumeral and/or the glenoacromial space. There was no correlation between shoulder pain and the development of ossification. Shoulders with grade III heterotopic bone formation had a limited range of active elevation compared with shoulders without or with only a milder lesion. Men and patients with osteoarthritis of the shoulder joint were significantly disposed to the development of heterotopic bone. Heterotopic bone formation following total shoulder arthroplasty is frequent, but disabling heterotopic ossifications seem to be rare.

Self-training versus physiotherapist-supervised rehabilitation of the shoulder in patients treated with arthroscopic subacromial decompression: A clinical randomized study

In a controlled clinical prospective study, 43 consecutive patients (43 shoulders) with subacromial impingement resistant to conservative therapy and without full-thickness rotator cuff tears underwent arthroscopic subacromial decompression. The patients were randomized to either self-training or physiotherapist-guided rehabilitation for immediate postoperative rehabilitation. Postoperative follow-up was performed by an independent observer after 3, 6, and 12 months. With the use of the Constant score for evaluation of functional outcome, patients training themselves improved from a mean 53 points (range 26 to 81 points) to a mean 79 points (range 45 to 100) points after 12 months. Physiotherapist-supervised patients improved from a mean 54 points (range 20 to 90 points) to a mean 80 points (range 40 to 100 points). The self-training patients returned to work after a mean 8.5 weeks (range 1 to 14 weeks), whereas the physiotherapist-supervised patients returned to work after a mean 8 weeks (range 3 to 13 weeks). No statistical difference was found between the 2 rehabilitation methods. This study was unable to show any beneficial effect of physiotherapist-supervised rehabilitation after arthroscopic subacromial decompression of the shoulder.

Glenohumeral movement patterns after puncture of the joint capsule: An experimental study

In on experimental series comprising 22 shoulder specimens obtained at autopsy, we investigated the influence of an intact capsule on glenohumeral stability. Puncture of the capsule resulted in significant glenohumeral translation in unloaded and loaded specimens during shoulder abduction. A maximum of 16.6 mm of distal translation was observed at 20° of abduction. Concomitant with this translation the humerus spontaneously rotated externally, with a maximum rotation of 15.8° at 50° of abduction. After venting the capsule, anterior and posterior translation and external rotation were increased significantly. Maximum total increase in anteroposterior translation was 14 mm at 30° of abduction. The external rotation was increased up to 7.1° at 40° of abduction. These findings indicate that studies evaluating glenohumeral instability are compromised unless the translations resulting from capsular venting ore corrected. Evaluation of shoulder stability should be performed before violation of the intraarticular pressure mechanisms.

The Pritchard Mark II elbow prosthesis in rheumatoid arthritis

Twenty-five consecutive rheumatoid elbows treated with the Pritchard Mark II elbow prosthesis were prospectively followed for 3 (2-5) years. There were marked pain relief and increased motion after the operation. Two elbows were revised, one because of deep infection and the other because of loosening. There were no neuropathies or fractures. The major long-term complication was radiographic loosening (6/24), which mainly occurred in elbows with only moderate rheumatoid destructions.