Vincent S. Carter

Patellar and quadriceps tendon ru p tures— jumper's knee:

We reviewed 13 patients with end stage jumpers knee, 10 with patellar tendon ruptures, and 3 with ruptures of the quadriceps tendon to evaluate our long-term results in treating these tendon ruptures in an athletic population. The focus was on the natural history, the time until return, and the level of return, to athletic activity. Jumpers knee affected all patients to a varying degree prior to rupture. Basketball was the most com mon sport involved. At followup, averaging 4½ years, patients underwent functional and clinical, as well as Cybex and roentgen ographic, evaluations. Results indicated patellar tendon ruptures, where the ruptures are complete, have a more favorable prognosis than those of the quadriceps ten don which are incomplete. All of the latter patients continued to have quadriceps tendinitis following repair. In both groups, the poor results were obtained in patients with chondromalacia and/or patella alta. Cybex testing yielded results of greater than 100% strength in three patients with patellar tendon ruptures, but no patient with quadriceps rupture had comparable test results. There was no apparent relationship between ruptures and cortisone injections. Patellar and quadriceps tendon ruptures from indirect injury in athletes represent the end stage of jumpers knee and result from repetitive microtrauma. Excellent function usually follows repair of patellar tendon rup tures when surgery is performed early and care is taken to restore normal patellar tendon length. Results of quadriceps ruptures are less satisfactory since these ruptures are usually incomplete and all degenerative tissue may not be involved in the healing response.

Shoulder impingement syndrome in athletes treated by an anterior acromioplasty.

Shoulder pain caused by a impingement syndrome commonly affects an athletes performance. Thirty-five shoulders in 33 athletes had an impingement syndrome treated by an anterior acromioplasty after failure of conservative treatment. Thirty-one of 35 shoulders (89%) were subjectively judged improved by the patients from their preoperative status. The moderate and severe pain was reduced from 97% of the shoulders preoperation to 20% postoperation. The pain at rest and with activities of daily living was reduced from 71% of the shoulders preoperation to 9% postoperation. However, only 15 of 35 operated shoulders (43%) allowed return to the same preinjury level of competitive athletics, and only four of 18 athletes involved in pitching and throwing returned to their former preinjury status. This operation is satisfactory for pain relief but does not allow an athlete to return to his former competitive status. A prolonged rehabilitation program may improve the results.

Degeneration and Rupture of the Achilles Tendon

An analysis was perfomed on 32 operative cases of Achilles tendon disease. Two patient classifications emerged. One group suffering an acute rupture of the Achilles tendon with no antecedent complaints, and the second group had a history of chronic pain, weakness and functional loss. This latter group could be further differentiated by the occurrence of tendon failure in 10 of 22 cases. Surgical exploration in the group with chronic complaints demonstrated a high incidence of diffuse reactive changes such as fibrinoid and myxomatous degeneration, fibroisis and metaplastic calcification. Degenerative disease of the Achilles tendon should be recognized and treated not as a simple injury but as a pathological lesion.

Correctable elbow lesions in professional baseball players: a review of 25 cases.

In a retrospective study, 20 of 25 professional baseball pitchers (mean age, 24 years; range, 19 to 28 years) who had had a reconstructive surgical procedure on the dominant elbow had satisfactory results (able to return to competitive throwing for one full season or more after surgery). Gentle motion was initiated 1 week after the operation on each patient. Exercises for mobilization and muscle strengthening of grip, arm, and shoulder were increased until throwing was initiated 10 to 12 weeks postoperatively. Throwing was gradually increased over several weeks from 30 feet at no more than half speed for 15 min to 60 feet at three-quarter speed. Pitchers were instructed to warm up before throwing and warm down and to continue this practice after they began competitive throwing. The longest period of follow-up has been 4 years (mean, 2.8 years). Four of the 25 pitchers had unsatisfactory results (released from their team in less than one full season because of ineffective pitching and were not picked up by another team). The cause of the release of the other patient-player is controversial. This 25- patient group is too small and the follow-up period is too short for definite conclusions. Our evidence does suggest that surgi cal procedures directed at medial soft tissue and posterior intra-articular changes carry better prognosis for competitive throwers than other procedures. The radiohumeral articular condition should be evaluated at surgery.

Posterior shoulder lesions in throwing athletes

Posterior shoulder lesions have terminated the careers of throwing athletes. We wish to present four case reports of posterior shoulder lesions which underwent operative intervention in an attempt to alleviate the individual’s symptomatology and permit a return to throwing. The four cases are those of active professional baseball players whose careers were all but terminated due to intractable posterior shoulder symptoms during and after throwing. None of the individuals responded to multiple conservative regimens. The basic operative approach in the four cases (F. W. J., primary surgeon) was as follows: with the patient prone and the involved extremity draped free, an incision was made over the scapula spine laterally; the deltoid was reflected from

The modified Bristow-Helfet procedure for recurrent anterior shoulder subluxations and dislocations

A review of 107 cases in which the Bristow-Helfet procedure was done for recurrent anterior shoulder subluxation and dislocation is presented. The redis location rate was 2% with very few complications. Eighty-nine percent of the patients were satisfied with the procedure. Mean loss of external rotation was 12.6°. Six of the 41 patients with dominant shoulder surgery were capable of throwing in the same manner as they did prior to injury. Five of 24 patients (21 %) with a diagnosis of recurrent anterior subluxation con tinued to have symptoms of instability following sur gery. Associated symptoms of posterior or voluntary subluxation may preclude a satisfactory result.

Osteochondritis of the capitellum

our charts, records and x-rays, we have prepared a report on a series of 36 patients with some type of injury or pathology of the capitellum. All of the patients in this series have been diagnosed as having had either osteochondritis dissecans or an osteochondral fracture of the capitellum. We determined to recall these patients in an attempt to ascertain why there had been an apparent increase in the number of patients with this

Iliotibial band transfer for anterolateral rotatory instability of the knee. Summary of 54 cases.

Forty-eight patients who underwent distal iliotibial band trans fer (Ellison) for anterolateral rotatory instability and who were over 1 year postsurgery presented for examination and an additional six patients completed a written subjective evalua tion. Five patients only had isolated lateral surgery. In 33 patients there was an additional diagnosis of anteromedial rotatory instability. Of the patients 44% had had no previous surgery, while 36% had undergone one procedure and 19% had undergone more than one procedure. In combination with iliotibial band transfer, 74% had a lateral meniscectomy, 44% had a capsular reefing, 38% had a medial meniscectomy, 44% had a pes anserinus transfer, and 8 patients had prosthetic cruciate ligament replacement. In these eight patients, five prosthetic ligaments had fractured and were included but three were intact and were excluded. Thirty-four percent of the patients were initially injured in football. All patients had thorough knee and radiographic examinations; strength mea surements by using the Cybex testing for knee extension; flexion and external rotation; and completed a subjective ques tionnaire. Of the patients 87% responded that they were im proved and thought the surgery was worthwhile. Ninety-one percent had positive jerk tests preoperatively but only 46% were positive at followup. However, while 53% reported no episodes of giving way, 28% reported monthly episodes, 9% weekly episodes, and 8% daily episodes. Only 15% had no difficulty cutting while 55% had some and 26% had extreme difficulty or were unable to do so. Only 23% reported no difficulty with jumping, but 48% had some difficulty, and 30% were unable to jump and had extreme difficulty jumping. Only 28% of patients had returned to their desired level of activity while 46% had reached only 50% of their desired level. Only 13% expressed complete confidence in the knee while 21 (46%) were in the 75 to 90% confidence range, while 22% had less than 50% confidence. Of the patients 29% had lost extension and 57% had lost flexion. Ninety-one percent had increased varus (adduction) instability at followup, but this did not appear to have clinical significance. On follow-up x-ray films 70% had osteophyte formation, 65% had joint space narrowing, 46% had pain requiring aspirin. Eighty percent had atrophy averaging 1.72 cm. Thirty percent had tenderness at Gerdys tubercle. As in all studies involving the knee ligaments, the many variables are dependent and poor results do not reflect failure of this one part of treatment. No patient was made worse by the procedure; there appears to be defmite reduction in anterolateral rotatory instability after iliotibial band transfer, which was maintained for more than 1 year after surgery.

Arthroscopy of the lateral meniscus in knees with normal arthrograms

O rthopedists taking care of competitive and recreational athletes are frequently asked to evaluate injured knees in these patients. The symptoms and examination may be vague, or specifically point to the patellofemoral, medial, or lateral compartments of the knee. Arthrography has been used to confirm a clinical impression, establish a diagnosis, and serve as an indication for surgical intervention, or both. Arthroscopy of the knee represents another method of evaluating knee pathology and of verifying a diagnosis that has been established clinically or at arthrography. Our previous clinical experience has indicated that arthrography, particularly of the lateral compartment, may be misleading. Has the arthroscope added to the evaluation of the lateral meniscus.

The patient's view of the pes anserinus transfer operation for rotatory instability of the knee

A review of 82 patients was performed to ascertain their subjective evaluations of the pes anserinus transfer procedure for rotatory instability of the knee. Analysis demonstrated a slow improvement in symptoms which occurred over a 12- month period. At that time, 62% of the patients had regained 90% of their preinjury confidence in knee stability.