Russell F. Warren

Arthroscopic fixation of superior labral lesions using a biodegradable implant: A preliminary report

Twenty-two patients were treated for symptomatic lesions of the superior glenoid labrum in association with instability of the tendinous insertion of the long head of the biceps brachii. A biodegradable implant was used to fix the labrum to the bony glenoid using an arthroscopic technique. At 2-year average follow-up, satisfactory results were obtained in 86% of the patients. Two patients, both of whom had undergone concomitant subacromial decompression, continued to complain of pain after the procedure; 3 patients had restricted motion postoperatively, and 1 required manipulation under anesthesia. Twelve of 13 overhead athletes were able to return to full premorbid function. Arthroscopic fixation of unstable lesions of the superior labrum led to a resolution of symptoms in the majority of patients. There were no complications related to the use of the biodegradable implant.

Traumatic Posterior Hip Subluxation in American Football

Background: Traumatic posterior hip subluxation is a potentially devastating injury that is often misdiagnosed as a simple hip sprain or strain. The purpose of the present study was to outline the injury mechanism, pathoanatomy, clinical and radiographic findings, and treatment of traumatic hip subluxation in an athletic population. Methods: Over a nine-year period, eight participants in American football who had sustained a traumatic posterior hip subluxation were evaluated and treated. The injury mechanism, clinical findings, and radiographic findings were reviewed. The mean duration of follow-up was thirty-four months. Results: The most common mechanism of injury was a fall on a flexed, adducted hip. Physical examination revealed painful limitation of hip motion. Initial radiographs demonstrated a characteristic posterior acetabular lip fracture. Initial magnetic resonance images revealed disruption of the iliofemoral ligament, hemarthrosis, and a viable femoral head. Two players were treated acutely with hip aspiration, and all eight players were treated with a six-week regimen of toe-touch weight-bearing with use of crutches. Six players recovered and returned to the previous level of competition. Two players had development of severe osteonecrosis and ultimately required total hip arthroplasty. Conclusion: The pathognomonic radiographic and magnetic resonance imaging triad of posterior acetabular lip fracture, iliofemoral ligament disruption, and hemarthrosis defines traumatic posterior hip subluxation. Patients in whom large hemarthroses are diagnosed on magnetic resonance images should undergo acute aspiration, and all players should be treated with a six-week regimen of toe-touch weight-bearing with use of crutches. Patients who have no sign of osteonecrosis on magnetic resonance imaging at six weeks can safely return to sports activity. Patients in whom osteonecrosis is diagnosed at six weeks are at risk for collapse and joint degeneration, and they should be advised against returning to sports. Level of Evidence: Prognostic study, Level IV (case series). See Instructions to Authors for a complete description of levels of evidence.

The efficacy of cryotherapy in the postoperative shoulder

We report the results of an outcome study that used visual analog scales to evaluate the efficacy of cryotherapy in the postoperative shoulder. This prospective study included 50 consecutive patients admitted to the hospital for at least one night after anterior shoulder stabilization, rotator cuff repair, or total shoulder replacement. The patients were randomized: 25 were fitted with a cryotherapy device in the operating room, and 25 were not. Otherwise, postoperative treatment was identical for the two groups, including types of analgesic agents given. Visual analog responses were converted to numeric values by simple measurement techniques. The scales assessed pain, comfort, sleep, analgesic use, and overall satisfaction. On the night of the operation the pain was less severe and occurred less often in the cryotherapy group. Those in the cryotherapy group slept better on the night of the operation and perceived the need to use pain medicine less often in comparison with those in the noncryotherapy group. By postoperative day 10 patients in the cryotherapy group reported their shoulders hurt less often and with less severity. Swelling was less, and shoulder movement hurt less during rehabilitation, enhancing the rehabilitative effort. Cryotherapy offers a number of benefits for care of patients in the immediate postoperative period.

Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome

Forty-two patients (65 shoulders) with osteonecrosis of the humeral head were reviewed. Minimal follow-up was 2 years or until shoulder arthroplasty was performed for persistent severe pain and disability not responsive to conservative treatment. Thirteen shoulders had surgery shortly after presentation, whereas 22 others initially treated conservatively required surgery. Thirty shoulders in 20 patients have been treated without surgery and were evaluated at an average of 10 years after initial presentation. Fifteen shoulders are doing satisfactorily, whereas 15 others are doing poorly. Overall, 37 (71%) shoulders had clinical progression of disease requiring shoulder arthroplasty or resulting in severe pain and disability. All had radiographic stage III, IV, or V, and 41 (85%) had articular surface incongruity of 2 mm or greater. Humeral head drilling was not effective in preventing clinical or radiographic progression in stage III.disease. Radiographic stages of III or greater and documented radiographic disease progression were significantly associated with a poor outcome.

Supporting layers of the glenohumeral joint. An anatomic study.

Based on anatomic and surgical dissections, the anatomy of the shoulder region is described in terms of four layers that overlie and support the glenohumeral joint. Each layer envelops the glenohumeral joint on its anterior, lateral, and posterior aspects, and between each layer there is a plane for safe and easy dissection. Layer 1 is composed of the deltoid and pectoralis major muscle bellies with their overlying fascia and enveloping epimysium. Anteriorly, Layer 2 consists of the clavipectoral fascia, the conjoined tendon of the short head of the biceps and coracobrachialis, and the coracoacromial ligament. Posteriorly, Layer 2 is the dense posterior scapular fascia that overlies the infraspinatus and teres minor muscle bellies. It is continuous with the clavipectoral fascia around the lateral aspect of the proximal humerus. Deep to Layer 2, the subdeltoid bursa yields a dissection plane that encompasses the anterior, lateral, superior, and variably the posterior aspects of the glenohumeral joint. Layer 3 consists of the deep layer of the subdeltoid bursa and the underlying musculotendinous units of the rotator cuff, including subscapularis, supraspinatus, infraspinatus, and teres minor. Layer 4 is the capsule of the glenohumeral joint. This includes the glenohumeral ligaments and coracohumeral ligament. These four layers were present and consistent in each shoulder dissected. Significant variations were present only within the deepest layer (shoulder joint capsule). This system can serve as a learning tool and will provide a more organized approach to facilitate surgical dissection in the region.