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Arthroscopic distal clavicle resections from a bursal approach
354
ABSTRACTS
mellitus. The duration of symptoms averaged 61 weeks (range, 30-113), and all patients failed a course of physical therapy addressing loss of motion in affected planes. Radiographs excluded a type III acromion in all patients. Six patients reported traction as the mechanism of injury, and 3 had a posterior capsular shift that was overly tightened. Eight of the 9 patients had a total of 14 unsuccessful operations prior to treatment. Results: Average preoperative range of motion (ROM) for the involved/noninvolved shoulder was 10°/ 58 ° (range, 0o-40°/50o-80°) for internal rotation at 90 ° of abduction (IRgo) and 133°/156 ° (range, 95 °- 150°/150 °170°) for forward flexion (FF). At arthroscopy, all patients had a thickened posterior capsule associated with a dynamic nonoutlet impingement which could be arthroscopically visualized as the ann was progressively forward flexed. All patients had arthroscopic posterior capsular release, with gentle manipulation to complete the release. At follow-up, an average of 14 months (range, 7-29), ROM for IR9o increased 37 ° (range, 30 °50 °) and ROM for FF increased 15° (range, -20°-45°). All patients noted substantial relief of pain, except for one who had articular cartilage changes due to prior intra-articular hardware and who was the only patient to lose motion, 20 ° of FF, in any plane. Discussion and Conclusion: The use of arthroscopic posterior capsular release, supplemented by manipulation, yielded substantial improvements in range of motion and pain in this group of refractory patients. Preoperatively, there was an average loss in IR9o was 48 ° compared with the noninvolved shoulder. This improved an average of 37 ° after surgery, resulting in a 9 ° deficit in IR90. For FF, the difference was 23 ° preoperatively, and a 15° increase was achieved, resuiting in an 8° deficit in FF. No instability was observed. Six patients described a traction injury, and the significance of this mechanism remains to be proven in light of the incidence of prior surgical procedures. While recognition of this refractory condition may be difficult, it can be successfully managed with an arthroscopic posterior capsular release technique.
Ankle SprainsQWhen the Pain Persists. The Role of Arthroscopic Surgery in Chronic Ankle Pain Following Inversion Sprains. D. J. Ogilvie-Harris. Toronto, Ontario, Canada. One hundred patients who had persistent ankle pain for more than 6 months following an inversion injury were investigated and treated. We found we could broadly classify the pathology into three groups: 1. The instabilities (lateral and syndesmotic). Arthroscopy, Vol 12, No 3, 1996
2. The impingement syndrome (anterior and anterolateral). 3. Chondral and osteochondral lesions (osteochondritis dissecans). The results were evaluated a minimum of one year and average of 3 years following arthroscopic intervention. Subjective symptoms of pain, swelling and stiffness, as well as functional assessment of limp, activity level and stability were assessed. The pre and postoperative results were analyzed statistically using non parametric tests. Number
Success (%)
Instability: Lateral (Evans) Syndesmotic
Diagnosis
23 13
20 (87%) 11 (85%)
Impingement: Anterior Anterolateral
11 15
10 (91%) 11 (74%)
Chondral fractures: With instability Without instability Loose bodies Osteochondral (osteochondral dissecans) Miscellaneous OA/Synovitis
9 12 5
3 (33%) 9 (75%) 5 (100%) 6 (86%) 2 (40%)
Arthroscopic Distal Clavicle Resections From a Bursal Approach. O. Alton Barron, Ken Yamaguchi, William N. Levine, Roger G. Pollock, Evan L. Flatow, and Louis U. Bigliani. New York, New York, and St. Louis, Missouri, U.S.A. Acromioclavicular joint (ACJ) pain is frequently seen with impingement syndrome and specifically needs to be addressed when performing an arthroscopic decompression. This study was performed to assess, in a small, well-defined, homogeneous series of patients, the results of arthroscopic resection of the distal clavicle performed as part of a subacromial decompression. Specific attention was given to technical factors which may lead to successful outcome. One hundred and seventeen consecutive patients who underwent arthroscopic ACJ arthroplasties were retrospectively reviewed. Only patients with bursal approaches performed in conjunction with subacromial decompressions were included. Patients with isolated ACJ arthrosis treated with resection of the distal clavicle from a superior approach, isolated impingement with only undersurface distal clavicle debridement, prior surgery, or other shoulder pathology were excluded. Twenty-four patients met these criteria for inclusion in the study. After a standard acromioplasty, the distal clavicle was visualized and an anterosuperior
ABSTRACTS portal was used to remove the distal clavicle. Following bony resection, the arthroscope was moved to the anterior portal to verify that the resection was even. Postop follow up averaged 32.5 months with a range of 24 to 70 mos. Preop and postop pain was rated subjectively on a 5-point scale. Patients were rated as excellent (no pain), good (minimal pain), and failure (all others). Operative reports and post operative radiographs were reviewed to determine technical factors which may have influenced outcome. In this series 87.5% of the patients had good or excellent results. 71% had excellent results, 16.5% had good, and 12.5% were considered failures. Average preop pain score was 1.8 and postop 4.3 (1 -- incapacitating pain, 5 = no pain). Given smooth, even and complete bone debridement, the amount of bone resected did not correlate with outcome. Arthroscopic distal clavicle resection performed in conjunction with subacromial decompression gave excellent results, comparable to isolated ACJ procedures. In this series, use of an anterior-superior portal for more direct shaver placement and complete ACJ viewing allowed consistent bone resection and excellent results in a high percentage of patients.
Surgical Treatment for Failed Anterior Acromioplasties: A Comparison of Arthroscopic and Open Revision Decompressions. Ken Yamaguchi, Patrick M. Connor, Roger G. Pollock, Evan L. Flatow, and Louis U. Bigliani. New York, New York, U.S.A. In this study, consecutive, recurrent populations of patients who underwent revision anterior acromioplasty by either arthroscopic or open means were compared to determine possible advantages in surgical approach and differences in outcome. Thirty-six consecutive patients who underwent revision subacromial decompression for refractory impingement syndrome were retrospectively studied. Patients with full thickness rotator cuff tears or failed acromioplasties secondary to misdiagnosis were excluded. All patients had persistent subacromial pain on the basis of clinical examination and differential injections. 18 patients underwent arthroscopic revision and 18 had open procedures. The dominant extremity was involved in 81% of the patients. The avg. age was 44 yrs. with an avg. of 42 yrs for the arthroscopic group and 45 yrs for the open. Average follow-up was 26 rot. 6/18 patients (33%) in the arthroscopic group and 12/18 (67%) in the open were worker's compensation (WC) patients. Patients were evaluated from clinical records including operative findings and by an out-
355
come based questionnaire. Pain preop and postop was subjectively graded by the patient from 0-10, with 0 being the worst pain. Seventeen of 18 patients (94%) were satisfied in the arthroscopic group as opposed to only 8/18 (44%) in the open group. Avg. pain score for the arthroscopic group improved from 1.8 to 7.8, while the open group improved from 1.4 to 5.3. In comparing WC patients, 5/6 (83%) were satisfied in the arthroscopic group as compared to 4/12 (33%) in the open. Avg. pain scores improved in the WC patients from 1.6 to 6.8 in arthroscopic and 1.3 to 4.8 in the open subgroups. For non WC patients, 12/12 (100%) in the arthroscopic and 4/ 6 (67%) of open patients were satisfied. Pain scores improved from 1.9 to 8.3 and 1.5 to 6.3 respectively. Residual, prominent bone or an acromial spur was found in only 20/36 (56%) of all patients with 7/18 (39%) arthroscopic and 13/18 (72%) open. The most common pathologic finding was dense subacromial scarring, present in all patients. In the arthroscopic group, 2/18 were found to have early DJD and 2/18 intraarticular adhesions, both treated with debridement. Revision subacromial decompression by arthroscopic means was found to be superior to open revision. However, there were more WC patients in the open group. WC patients fared worse for both subgroups, but a significant proportion (83%) of the arthroscopic group was satisfied. As subacromial scaring (100% patients) may be the most important pathology, the arthroscopic approach is possibly more effective by being less invasive, thus allowing earlier unrestricted use of the arm.
Fracture of the Proximal Tibia With Immediate Weight Bearing Following Fulkerson Osteotomy. William B. Stetson, Marc J. Friedman, John P. Fulkerson, Margaret S. Cheng, and David Buuck. St. Louis, Missouri, Van Nuys, California, Farmington, Connecticut, and San Jose, California, U.S.A.
Introduction: Anteromedial tibial tubercle transfer via oblique osteotomy was first described by Fulkerson in 1983 for the treatment of patellofemoral malalignment. The purpose of our paper is to report a complication of the Fulkerson osteotomy: Fracture of the proximal tibial which occurred in 6 patients. Methods: The records of 234 patients who underwent anteromedialization of the tibial tubercle via oblique osteotomy from 1983 through 1994 at the Southern California Orthopedic Institute and at the University of Connecticut were retrospectively reviewed. Six patients were noted to have suffered a Arthroscopy, Vol 12, No 3, 1996
ABSTRACTS
mellitus. The duration of symptoms averaged 61 weeks (range, 30-113), and all patients failed a course of physical therapy addressing loss of motion in affected planes. Radiographs excluded a type III acromion in all patients. Six patients reported traction as the mechanism of injury, and 3 had a posterior capsular shift that was overly tightened. Eight of the 9 patients had a total of 14 unsuccessful operations prior to treatment. Results: Average preoperative range of motion (ROM) for the involved/noninvolved shoulder was 10°/ 58 ° (range, 0o-40°/50o-80°) for internal rotation at 90 ° of abduction (IRgo) and 133°/156 ° (range, 95 °- 150°/150 °170°) for forward flexion (FF). At arthroscopy, all patients had a thickened posterior capsule associated with a dynamic nonoutlet impingement which could be arthroscopically visualized as the ann was progressively forward flexed. All patients had arthroscopic posterior capsular release, with gentle manipulation to complete the release. At follow-up, an average of 14 months (range, 7-29), ROM for IR9o increased 37 ° (range, 30 °50 °) and ROM for FF increased 15° (range, -20°-45°). All patients noted substantial relief of pain, except for one who had articular cartilage changes due to prior intra-articular hardware and who was the only patient to lose motion, 20 ° of FF, in any plane. Discussion and Conclusion: The use of arthroscopic posterior capsular release, supplemented by manipulation, yielded substantial improvements in range of motion and pain in this group of refractory patients. Preoperatively, there was an average loss in IR9o was 48 ° compared with the noninvolved shoulder. This improved an average of 37 ° after surgery, resulting in a 9 ° deficit in IR90. For FF, the difference was 23 ° preoperatively, and a 15° increase was achieved, resuiting in an 8° deficit in FF. No instability was observed. Six patients described a traction injury, and the significance of this mechanism remains to be proven in light of the incidence of prior surgical procedures. While recognition of this refractory condition may be difficult, it can be successfully managed with an arthroscopic posterior capsular release technique.
Ankle SprainsQWhen the Pain Persists. The Role of Arthroscopic Surgery in Chronic Ankle Pain Following Inversion Sprains. D. J. Ogilvie-Harris. Toronto, Ontario, Canada. One hundred patients who had persistent ankle pain for more than 6 months following an inversion injury were investigated and treated. We found we could broadly classify the pathology into three groups: 1. The instabilities (lateral and syndesmotic). Arthroscopy, Vol 12, No 3, 1996
2. The impingement syndrome (anterior and anterolateral). 3. Chondral and osteochondral lesions (osteochondritis dissecans). The results were evaluated a minimum of one year and average of 3 years following arthroscopic intervention. Subjective symptoms of pain, swelling and stiffness, as well as functional assessment of limp, activity level and stability were assessed. The pre and postoperative results were analyzed statistically using non parametric tests. Number
Success (%)
Instability: Lateral (Evans) Syndesmotic
Diagnosis
23 13
20 (87%) 11 (85%)
Impingement: Anterior Anterolateral
11 15
10 (91%) 11 (74%)
Chondral fractures: With instability Without instability Loose bodies Osteochondral (osteochondral dissecans) Miscellaneous OA/Synovitis
9 12 5
3 (33%) 9 (75%) 5 (100%) 6 (86%) 2 (40%)
Arthroscopic Distal Clavicle Resections From a Bursal Approach. O. Alton Barron, Ken Yamaguchi, William N. Levine, Roger G. Pollock, Evan L. Flatow, and Louis U. Bigliani. New York, New York, and St. Louis, Missouri, U.S.A. Acromioclavicular joint (ACJ) pain is frequently seen with impingement syndrome and specifically needs to be addressed when performing an arthroscopic decompression. This study was performed to assess, in a small, well-defined, homogeneous series of patients, the results of arthroscopic resection of the distal clavicle performed as part of a subacromial decompression. Specific attention was given to technical factors which may lead to successful outcome. One hundred and seventeen consecutive patients who underwent arthroscopic ACJ arthroplasties were retrospectively reviewed. Only patients with bursal approaches performed in conjunction with subacromial decompressions were included. Patients with isolated ACJ arthrosis treated with resection of the distal clavicle from a superior approach, isolated impingement with only undersurface distal clavicle debridement, prior surgery, or other shoulder pathology were excluded. Twenty-four patients met these criteria for inclusion in the study. After a standard acromioplasty, the distal clavicle was visualized and an anterosuperior
ABSTRACTS portal was used to remove the distal clavicle. Following bony resection, the arthroscope was moved to the anterior portal to verify that the resection was even. Postop follow up averaged 32.5 months with a range of 24 to 70 mos. Preop and postop pain was rated subjectively on a 5-point scale. Patients were rated as excellent (no pain), good (minimal pain), and failure (all others). Operative reports and post operative radiographs were reviewed to determine technical factors which may have influenced outcome. In this series 87.5% of the patients had good or excellent results. 71% had excellent results, 16.5% had good, and 12.5% were considered failures. Average preop pain score was 1.8 and postop 4.3 (1 -- incapacitating pain, 5 = no pain). Given smooth, even and complete bone debridement, the amount of bone resected did not correlate with outcome. Arthroscopic distal clavicle resection performed in conjunction with subacromial decompression gave excellent results, comparable to isolated ACJ procedures. In this series, use of an anterior-superior portal for more direct shaver placement and complete ACJ viewing allowed consistent bone resection and excellent results in a high percentage of patients.
Surgical Treatment for Failed Anterior Acromioplasties: A Comparison of Arthroscopic and Open Revision Decompressions. Ken Yamaguchi, Patrick M. Connor, Roger G. Pollock, Evan L. Flatow, and Louis U. Bigliani. New York, New York, U.S.A. In this study, consecutive, recurrent populations of patients who underwent revision anterior acromioplasty by either arthroscopic or open means were compared to determine possible advantages in surgical approach and differences in outcome. Thirty-six consecutive patients who underwent revision subacromial decompression for refractory impingement syndrome were retrospectively studied. Patients with full thickness rotator cuff tears or failed acromioplasties secondary to misdiagnosis were excluded. All patients had persistent subacromial pain on the basis of clinical examination and differential injections. 18 patients underwent arthroscopic revision and 18 had open procedures. The dominant extremity was involved in 81% of the patients. The avg. age was 44 yrs. with an avg. of 42 yrs for the arthroscopic group and 45 yrs for the open. Average follow-up was 26 rot. 6/18 patients (33%) in the arthroscopic group and 12/18 (67%) in the open were worker's compensation (WC) patients. Patients were evaluated from clinical records including operative findings and by an out-
355
come based questionnaire. Pain preop and postop was subjectively graded by the patient from 0-10, with 0 being the worst pain. Seventeen of 18 patients (94%) were satisfied in the arthroscopic group as opposed to only 8/18 (44%) in the open group. Avg. pain score for the arthroscopic group improved from 1.8 to 7.8, while the open group improved from 1.4 to 5.3. In comparing WC patients, 5/6 (83%) were satisfied in the arthroscopic group as compared to 4/12 (33%) in the open. Avg. pain scores improved in the WC patients from 1.6 to 6.8 in arthroscopic and 1.3 to 4.8 in the open subgroups. For non WC patients, 12/12 (100%) in the arthroscopic and 4/ 6 (67%) of open patients were satisfied. Pain scores improved from 1.9 to 8.3 and 1.5 to 6.3 respectively. Residual, prominent bone or an acromial spur was found in only 20/36 (56%) of all patients with 7/18 (39%) arthroscopic and 13/18 (72%) open. The most common pathologic finding was dense subacromial scarring, present in all patients. In the arthroscopic group, 2/18 were found to have early DJD and 2/18 intraarticular adhesions, both treated with debridement. Revision subacromial decompression by arthroscopic means was found to be superior to open revision. However, there were more WC patients in the open group. WC patients fared worse for both subgroups, but a significant proportion (83%) of the arthroscopic group was satisfied. As subacromial scaring (100% patients) may be the most important pathology, the arthroscopic approach is possibly more effective by being less invasive, thus allowing earlier unrestricted use of the arm.
Fracture of the Proximal Tibia With Immediate Weight Bearing Following Fulkerson Osteotomy. William B. Stetson, Marc J. Friedman, John P. Fulkerson, Margaret S. Cheng, and David Buuck. St. Louis, Missouri, Van Nuys, California, Farmington, Connecticut, and San Jose, California, U.S.A.
Introduction: Anteromedial tibial tubercle transfer via oblique osteotomy was first described by Fulkerson in 1983 for the treatment of patellofemoral malalignment. The purpose of our paper is to report a complication of the Fulkerson osteotomy: Fracture of the proximal tibial which occurred in 6 patients. Methods: The records of 234 patients who underwent anteromedialization of the tibial tubercle via oblique osteotomy from 1983 through 1994 at the Southern California Orthopedic Institute and at the University of Connecticut were retrospectively reviewed. Six patients were noted to have suffered a Arthroscopy, Vol 12, No 3, 1996