Faculty Bibliography

Femoroacetabular impingement results from an abnormal contact between the femur and the pelvis. This abnormal contact leads to developmental changes in the femoral neck, labrum, and acetabulum. Secondary to the altered hip joint mechanics, chondral damage occurs and initiates the degenerative process, eventually leading to osteoarthritis. Numerous etiologies have been implicated in femoroacetabular impingement, and a variety of treatment algorithms have been established, with no definitive gold standard. However, the treatment of this disorder with joint preserving techniques offers a viable option between the extremes of nonoperative treatment and total joint arthroplasty

The long head of the biceps has been described as a stabilizing force in the setting of glenohumeral instability. However, data are lacking on the effect of loading the long head of the biceps on glenohumeral kinematics. Six cadaveric shoulders were tested for glenohumeral rotational range of motion and translation using a custom shoulder testing system and the Microscribe 3DLX (Immersion, San Jose, CA). The path of glenohumeral articulation (PGA) was measured by calculating the humeral head center with respect to the glenoid articular surface at maximal internal rotation, 30 degrees, 60 degrees, 90 degrees, and maximal external rotation. Significant decreases in glenohumeral rotational range of motion and translation were found with 22-N biceps loading vs the unloaded group. With respect to the PGA, the humeral rotation center was shifted posterior with biceps loading at maximal internal rotation, 30 degrees, and 60 degrees of external rotation. Loading the long head of the biceps significantly affects glenohumeral rotational range of motion, translations, and kinematics

BACKGROUND: Previous studies have demonstrated increased glenohumeral translations with simulated type II superior labral anterior posterior lesions, which may explain the sensation of instability in the overhead-throwing athlete. It is unknown whether this amount of increased translation alters glenohumeral kinematics. PURPOSE: To determine whether type II superior labral anterior posterior lesions significantly alter glenohumeral kinematics as defined by path of glenohumeral articulation in a simulated cadaveric model of the throwing shoulder. STUDY DESIGN: Controlled laboratory study. METHODS: Six cadaveric shoulders were tested for glenohumeral rotational range of motion and translation using a custom shoulder testing system and the Microscribe 3DLX. The path of glenohumeral articulation was measured by calculating the humeral head center with respect to the glenoid articular surface at maximal internal rotation, 30 degrees, 60 degrees, 90 degrees, and maximal external rotation. Data were recorded for vented intact shoulders, shoulders with arthroscopically created type II superior labral anterior posterior lesions, and shoulders with arthroscopically repaired superior labral anterior posterior lesions. RESULTS: A subtle but significant increase in external rotation (2.7 degrees) was seen after creating a type II lesion. Small increases in glenohumeral translation were found in the anterior (0.9 mm) and inferior (0.9 mm) directions with application of a 15-N force in the superior labral anterior posterior group. Increases in glenohumeral rotation and translation were restored to the intact state after repair of the lesion. No significant differences were found in the path of glenohumeral articulation for the superior labral anterior posterior condition compared with the intact shoulder. CONCLUSION: The small amounts of increased external rotation and translation found with arthroscopically created type II superior labral anterior posterior lesions do not significantly affect glenohumeral kinematics in this passive motion model as quantified by the path of glenohumeral articulation. CLINICAL RELEVANCE: Findings suggest that in the absence of pain or mechanical symptoms, type II superior labral anterior posterior lesions that do not significantly involve the superior and middle glenohumeral ligaments may not need surgical repair

The case of a patient is presented in whom a No. 11 scalpel blade was inadvertently broken and embedded within the lateral femoral condyle during initial arthroscopic portal creation. After a thorough diagnostic arthroscopy and synovectomy to expose the distal femoral articular surface was unsuccessful, luoroscopy was performed to localize the blade fragment in orthogonal planes. The blade tip was eventually retrieved from its position below the surface of the cartilage. The details of the loss and recovery of the blade fragment reinforce that exceptional care must be taken and attention given during the creation of portals, particularly when resistance is encountered. Additionally, all instruments, especially scalpel blades, should be exam- ined carefully when removed from the knee joint

The posterolateral region of the knee is an anatomically complex area that plays an important role in the stabilization of the knee relative to specific force vectors at low angles of knee flexion. A renewed interest in this region and advanced biomechanical studies have brought additional understanding of both the anatomy and the function of posterolateral structures in knee stabilization and kinematics. Through sectioning and loading studies, the posterolateral corner has been shown to play a role in the prevention of varus angulation, external rotation, and posterior translation. The potential for long-term disability from these injuries may be related to increased articular pressure and chondral degeneration. The failure of the reconstruction of cruciate ligaments may be due to unrecognized or untreated posterolateral corner injuries. Various methods of repair and reconstruction have been described and new research is yielding superior results from reconstruction of this region

Decubitus ulcers, commonly known as pressure ulcers or sores, represent localized areas of tissue necrosis. Despite increased awareness and use of preventive measures, these ulcers remain a major concern in the hospitalized and immobile patient population. When the hip joint becomes infected or the wound remains refractory to nonsurgical treatments, the orthopedic surgeon becomes involved in patient care. In this review, a brief overview of decubitus ulcers and their nonsurgical management is given, followed by a discussion of various flaps used in more extensive repairs. The major orthopedic procedures presented include proximal femoral resection (Girdlestone procedure), hip disarticulation, and hemipelvectomy. These surgeries retain an important position in managing complicated decubitus ulcers around the proximal femur

PURPOSE: To describe a case series of 10 consecutive patients with spinoglenoid cysts and associated superior labral tears treated by labral repair performed by the same surgeon without formal cyst aspiration, debridement, or excision. METHODS: Ten patients with spinoglenoid cysts and associated superior labral tears demonstrated on preoperative magnetic resonance imaging (MRI) were retrospectively reviewed. Evidence of weakness on examination was further evaluated through nerve conduction studies. All 10 patients underwent surgical repair of the labral tear performed by the same surgeon without formal cyst aspiration, debridement, or excision. Postoperatively, detailed shoulder and neurologic examinations were performed, and follow-up nerve conduction studies and MRIs were obtained. RESULTS: Ten patients were evaluated clinically at a mean of 10.2 months after surgical repair (range, 6 to 27 months). In all, 8 males and 2 females of average age 47.7 years (range, 35 to 56 years) were studied. Preoperative examination revealed that 6 patients had external rotation weakness. Nerve conduction studies performed in these 6 patients confirmed suprascapular neuropathy in 4 of them. Labral repair without formal cyst excision resulted in successful outcomes for all 10 patients after spinoglenoid cysts associated with superior labral tears had been diagnosed. All 4 patients with suprascapular neuropathy recovered strength and demonstrated normal nerve conduction studies postoperatively. In 8 of 10 patients, MRIs performed postoperatively demonstrated complete resolution of the cyst, along with labral healing. All patients were able to return to work with no restrictions on activities, and all were satisfied with their outcomes. CONCLUSIONS: This study demonstrated successful clinical, electromyographic, and MRI outcomes for patients with spinoglenoid cysts and superior labral tears, who were treated by labral repair without formal cyst excision. Treatment given for intra-articular disease is the key component of surgical management. LEVEL OF EVIDENCE: Level IV, case series study

This study compares the results of arthroscopic and arthroscopically assisted mini-open rotator cuff repair in a series of 84 patients who underwent repair of small, medium, or large tears between March 1997 and September 2001 with at least 2 years of follow-up. There were 42 arthroscopic repairs and 42 mini-open repairs. Of the patients, 81 (96.4%) had good or excellent UCLA (University of California, Los Angeles) scores (40 arthroscopic repairs [95.2%] and 41 mini-open repairs [97.6%]); there were 2 fair results and 1 poor outcome. The ASES (American Shoulder and Elbow Surgeons) scores averaged 91.1 for the arthroscopic group and 90.2 for the mini-open group (P > .05). Six patients required further surgery (three from the arthroscopic group and three from the mini-open group). Of 84 patients, 83 (98.8%) reported being satisfied with the procedure. At greater than 2 years of follow-up, arthroscopic and mini-open rotator cuff repairs produced similar results for small, medium, and large rotator cuff tears with equivalent patient satisfaction rates

Os acromiale is a developmental aberration in which the distal acromion fails to fuse. This aberration is often discovered incidentally but may present with a clinical picture similar to that of subacromial impingement syndrome. Treatment for symptomatic os acromiale is initially nonoperative-activity modification, physical therapy, corticosteroid injection, use of nonsteroidal anti-inflammatory medication. Nonoperative management of clinically significant, radiographically confirmed os acromiale should be pursued for at least 6 months before consideration of surgical intervention. Subacromial decompression is often necessary to address symptoms of impingement. Excision of the os fragment may provide definitive treatment for smaller fragments (<3 cm). Removal of larger fragments remains controversial and should be approached with caution. Surgical fixation of larger fragments with or without supplemental autograft in conjunction with a structured postoperative program of physical therapy can reliably provide relief for symptomatic os acromiale

Despite major advances in the field of total joint arthroplasty, a standardized postoperative management protocol currently does not exist following total hip arthroplasty (THA) and total knee arthroplasty (TKA). A survey was mailed to the active members of the American Association of Hip and Knee Surgeons to investigate issues such as postoperative rehabilitation and activity restriction. The information derived from this survey provides the total joint surgeon with a compilation and consensus of responses that can serve as the foundation for a standardized postoperative protocol for THA and TKA surgery