Biomedical subjects
Publications and source records attributed to F Cuomo.
A 33-year-old male presented with acute onset of scapular winging following an injury to the shoulder girdle. A scapular osteochondroma was identified radiographically that was completely asymptomatic until the time of injury. Clinical presentation included the presence of a large exostosis bursata. Surgical resection of the osteochondroma resulted in resolution of all signs and symptoms.
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Twelve patients, ranging in age from thirty-four to seventy-two years (average, fifty-three years), were evaluated an average of five years (range, two to eight years) after open reduction and internal fixation of a two-part displaced fracture of the greater tuberosity of the proximal part of the humerus. The indication for operative reduction was one centimeter or more of displacement of the fracture as seen on the diagnostic radiographs. The anterosuperior deltoid-splitting approach, combined with rotation of the humerus, allowed adequate exposure of the retracted tuberosity. Internal fixation of the greater tuberosity with heavy, non-absorbable sutures and careful repair of the rotator cuff permitted early passive motion. All fractures healed without postoperative displacement. Six patients had an excellent result and six had a good result; active elevation averaged 170 degrees. There was one partial, transient palsy of the axillary nerve.
Shoulder disorders are most commonly manifested by pain and limited function. Careful history and examination help the physician localize the problem to the shoulder joint, the surrounding tissues or adjacent sites that can cause referred pain to the shoulder. Common extrinsic causes of shoulder pain include postural problems and cervical spine disorders.
Intrinsic disorders that can cause shoulder pain include arthritis, gout, pseudogout and osteonecrosis. In its mildest form, impingement syndrome may cause only minimal discomfort. At its worst, impingement syndrome may lead to rotator cuff tear. Bicipital tendinitis and rupture of the biceps tendon may also be associated with impingement. Early rehabilitative intervention is important. Physical therapy is directed toward restoring range of motion and muscle strength.
Fifty-two patients (sixty knees) who had a diagnosis of either patellar subluxation or dislocation had an operation consisting of a lateral release and proximal realignment of the patella. The duration of follow-up ranged from two to nine years. At the latest follow-up, forty-two (80.8 per cent) of the patients had a good or an excellent clinical result; only one patient had redislocation of the patella. The results were not affected by the grade of chondromalacia that was present at the time of operation; however, the differences in the results as correlated with the age and sex of the patient were statistically significant, the older patients having poorer results and the male patients, better results. Roentgenographic analysis of the postoperative position of the patella, as seen on the view described by Merchant et al., revealed that centralizing the patella in the intercondylar sulcus yielded the most favorable results.
Twenty-six hemiarthroplasties were performed for acute three- and four-part proximal humerus fractures between March 1986 and December 1991. Postoperative pain, active range of motion, and function were evaluated in 22 patients at a mean follow-up period of 30 months (range 12 to 66 months) with the American Shoulder and Elbow Surgeons evaluation form. Seventy-three percent of patients reported only slight or no pain. Active forward elevation averaged 107 degrees, external rotation averaged 31 degrees, and the average internal rotation was to the second lumbar vertebra. Strength and stability were rarely problematic. Seventy-three percent of patients reported difficulty with at least three of 15 functional tasks tested. Lifting, carrying a weight, and using the hand at or above shoulder level were the most common limitations. This study indicates that hemiarthroplasty for acute three- and four-part fractures generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable.
Forty-two consecutive patients (20 men and 22 women, age range 39 to 78 years) with full-thickness rotator cuff tears underwent a comprehensive isokinetic strength assessment before and at 3-month intervals for 1 year after surgery. All patients underwent acromioplasty and rotator cuff repair and were treated with a standardized postoperative rehabilitation program. Isokinetic strength testing was performed in flexion/extension, abduction/adduction, and external/internal rotation at 60 degrees/sec. The unaffected contralateral shoulder was tested for comparison. Clinical outcomes were assessed with the University of California Los Angeles Shoulder Rating Scale (maximum = 35 points). The average University of California Los Angeles score was 31.2 by 1 year after operation. Patients with small and medium tears had an average rating of 33.5, whereas those with large and massive tears had an average score of 28.3. Strength increased gradually during the first postoperative year. The preoperative mean peak torque was 54%, 45%, and 64% of the uninvolved shoulder in flexion, abduction, and external rotation, respectively; after operation it increased to 78%, 80%, and 79% by 6 months and 84%, 90%, and 91% by 12 months. The greatest improvement in strength consistently occurred during the first 6 months after surgery. Patients also showed marked increases in both work and power. By 12 months after operation mean work had increased to 70% in flexion and abduction and 90% in external rotation of the uninvolved shoulder. Similarly, mean power had increased to 68%, 79%, and 90% of the uninvolved shoulder in flexion, abduction, and external rotation, respectively, by 12 months after operation. Recovery of strength correlated primarily with the size of the tear: for small and medium tears recovery of strength was almost complete during the first year, and for large and massive tears it was much slower and less consistent. By using isokinetic strength evaluation we found that recovery of strength after rotator cuff repair requires at least 1 year of rehabilitation.
Bilateral shoulder motor output measurements were obtained in 40 subjects with a Biodex dynamometer. The subjects included two groups, a younger group (20 to 30 years) and an older group (50 to 60 years). They were engaged in low to moderate levels of occupational and spare-time physical activity. Each subject performed three maximum effort shoulder movements in flexion/extension, abduction/adduction, and internal/external rotation at 60 degrees/sec and 120 degrees/sec. Side tested, axis, and speed were randomly selected. The findings indicate that a significant decline occurred in peak torque, work, and power for all axes of movement at both speeds when the older group was compared with the younger group. A decline in peak torque and work and a corresponding increase in power resulting from an increase in speed occurred in both age groups. The effect of age was the same at 60 degrees/sec and at 120 degrees/sec. Overall, no difference in dominant and nondominant motor function was seen in either the younger or older untrained men.
The strength of active flexion/extension and supination/pronation was measured isokinetically in 60 right-hand-dominant nonathletic men. They were equally divided into a younger group (20 to 30 years) and an older group (50 to 60 years) with moderate occupational and spare-time activity levels. Peak torque, work, power, and the angle of peak torque production were measured bilaterally at a slow (90 degrees/sec) and a fast (180 degrees/sec) speed of movement. Although highly significant differences were found between the young and older groups in flexion and extension, no age-related differences were found in supination and pronation. The dominant side had significantly higher levels of peak torque, work, and power in flexion; however, no significant differences were detected in peak torque for extension, supination, and pronation. Isokinetic peak torque and work were greater at the slower speed as opposed to power, which was significantly greater at the faster speed with the exception of pronation movement. With regard to the angle where peak torque was achieved, significant differences were detected between groups, which suggests that age appears to affect where in the range of motion peak torque is produced.
One hundred ten acromial anatomic specimens were classified by three shoulder surgeons with the classification system described by Bigliani et al. to determine the interobserver reliability. These results demonstrated a fair to poor level of interobserver reliability. Given this relatively low level of agreement, the diagnosis of impingement and rotator cuff tears should be based on clinical findings supplemented, when indicated, by rotatory cuff imaging with less diagnostic reliance placed on the assessment of acromial morphology.
A detailed anatomic study of 123 shoulders was performed to define the location of the acromioclavicular (AC) joint within the supraspinatus outlet and to determine the correlation of AC joint morphologic characteristics with the presence of full-thickness rotator cuff tears (RCTs). The presence, location, and extent of RCTs were first documented for each shoulder, and 2 anatomic landmarks consisting of the anterolateral acromial corner and the inferior midpoint of the AC joint were identified and their positions digitized in 3 dimensions to calculate outlet space and clearance and AC joint locations. High resolution x-ray films were then obtained to determine the extent of degenerative changes including the location and size of inferior osteophytes and joint space. These specimens were cleaned of all soft tissues, and additional measurements were made. All data were entered into a computerized database and analyzed with respect to age, sex, and the presence of RCT. Comparison of age-matched RCT versus non-RCT groups revealed no significant differences in the position of the AC joint within the supraspinatus outlet. When AC joint morphologic characteristics were compared with those of a nontear, age-matched group, no significant differences with regard to joint space narrowing were found, but significantly larger and greater number of osteophytes were identified on both sides of the joint in the RCT group. In conclusion, the position of the AC joint is fairly constant within the supraspinatus outlet and does not appear to predispose to RCTs. The morphology of the AC joint contribution of the tears seems to be acquired in nature rather than inherent in its location within the outlet.
Twenty uninjured male volunteers were studied to characterize normal elbow proprioception and to investigate the effect of applying an elastic bandage to the extremity and injection of an intraarticular anesthetic. A modified Biodex dynamometer was used to study position sense and detection of motion. In part 1 of the study position sense was tested by flexing the elbow to a predetermined angle, returning to the starting position, and then asking the subject to identify that angle. In part 2 detection of motion was tested by asking the subject to disengage the apparatus by pressing a stop button when movement was detected. The testing conditions in part 1 and part 2 were repeated after the elbow was wrapped with an elastic bandage and again after an intraarticular injection of 3 cc 1% lidocaine with the bandage removed. Ten additional subjects underwent testing of both elbows to examine the effect of arm dominance. Mean position sense was within 3.3 degrees+/-1.3 degrees of the actual angle in trials without an elastic bandage or an anesthetic. A significant improvement in position sense was observed (2.2 degrees+/-1.2 degrees) after an elastic bandage was applied (P < .004). No significant difference was seen in position sense after lidocaine was injected. The mean threshold for detection of motion in trials without an elastic bandage or an anesthetic was 4.21 degrees+/-1.56 degrees. No significant differences were seen in detection of motion observed with the elastic bandage or intraarticular anesthetic. No significant differences were seen between dominant and nondominant extremities for both position sense and detection of motion. The application of an elastic bandage improved position sense, suggesting that tactile cues from cutaneous or other extraarticular receptors may play a role in elbow proprioception. Intraarticular anesthesia, however, had little effect, suggesting that intracapsular receptors play a lesser role in elbow proprioception. The determination of proprioceptive qualities for the normal elbow can aid in the understanding of elbow function and provide a basis for defining its role in elbow dysfunction.
Magnetic resonance arthrography is superior to other imaging techniques in evaluation of the glenohumeral joint. Normal variants that can be diagnostic pitfalls include the anterosuperior sublabral foramen, the Buford complex, and hyaline cartilage under the labrum. Anteroinferior dislocation is the most frequent cause of anterior glenohumeral instability and produces a constellation of lesions (anteroinferior labral tear, classic and osseous Bankart lesions, Hill-Sachs lesion). Variants of anteroinferior labral tears include anterior labroligamentous periosteal sleeve avulsion and glenoid labral articular disruption. Anterior glenohumeral instability can also involve tears of the anterior or anterosuperior labrum or the glenohumeral ligaments. Posterior glenohumeral instability can involve a posterior labral tear, posterior capsular stripping or laxity; fracture, erosion, or sclerosis and ectopic ossification of the posterior glenoid fossa; reverse Hill-Sachs lesion; McLaughlin fracture; or posterosuperior glenoid impingement. Superior labral anterior and posterior lesions involve the superior labrum with varying degrees of biceps tendon involvement.
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