Biomedical subjects
Publications and source records attributed to L A Norwood.
This report describes an unusual opportunistic fungal infection in an immunocompetent young man who had no cutaneous involvement and whose infection was diagnosed 6 years after an accident. The unusual clinical presentation and difficulties in making a correct diagnosis are discussed and prophylactic antifungal chemotherapy is suggested.
No characteristic clinical presentation of pigmented villonodular synovitis of the shoulder can yet be determined. Symptoms of discomfort and stiffness may appear insidiously or, in some cases, pigmented villonodular synovitis may be found incidentally during surgery for unrelated problems. Cystic and degenerative changes are more likely to occur in the shoulder than in joints with large synovial recesses such as the knee. Histologic findings parallel those in other joints. Optimal treatment appears to be early marginal excision for the localized form or total synovectomy for the diffuse form. The incidental finding of pigmented villonodular synovitis should not influence the decision to proceed with a preplanned reconstructive procedure. No experience with arthroscopic treatment or radiation therapy for diffuse pigmented villonodular synovitis of the shoulder has been reported.
To determine whether the presence and extent of a tear of the rotator cuff could be predicted on the basis of a patient's history, physical examination, and radiographic findings, detailed data from the histories and physical examinations of 103 patients who were known to have a tear of the rotator cuff were correlated with the radiographic and operative findings on these patients. An age-matched control group of fifty-one patients who had similar symptoms, but whose arthrograms showed normal results, was used to establish a baseline incidence of ten specific radiographic findings in the shoulder. Two discrete groups of patients who had a tear of the rotator cuff were identified. Twenty-eight patients (27 per cent) had a tear of a single tendon; the histories and the physical and radiographic findings in this group were consistent with a symptomatic local mechanical-impingement process in the shoulder. Sixty (80 per cent) of the seventy-five patients in the other group had a history of acute trauma to a shoulder. The patients in this second group were older and were non-athletic, and had not previously had symptoms that were severe enough to need treatment. These patients were subsequently found to have a complete tear of more than one of the tendons of the rotator cuff. Multiple radiographic findings in the shoulder and other coexisting orthopaedic conditions also were more common in these patients. In this group, we believe that acute trauma in a shoulder that had chronic degenerative changes, rather than localized mechanical impingement, caused the tendons to rupture.
Eighteen patients with isolated chondral fractures of the knee were reviewed to reevaluate the clinical signs and symptoms. No other conditions had been present to account for the symptoms. Most of the patients had significant injuries often involving a flexed knee. All patients had had symptoms and physical findings strongly suggestive of meniscal abnormality. Roentgenographic examinations were noncontributory. The lesions occurred in four distinct patterns. All were full thickness. Many of the lesions occurred on the posterior aspect of a femoral condyle, a location where they could be easily overlooked if the condyle were not examined with the knee in extreme flexion. Abutment of the tibial spine against the medial femoral condyle may be one cause of these injuries. The incidence of isolated chondral fractures was found to be higher than previously reported. A negative arthroscopic meniscal examination in a patient with symptoms and physical findings suggestive of meniscal abnormality should alert the physician to the possibility of an isolated chondral fracture.
This article provides an account of the experience at the Hughston Orthopaedic Clinic in diagnosing and treating acute anterolateral rotatory instability of the knee. Clinical evaluation, surgical exposure and repair, and postoperative rehabilitation are detailed, with emphasis on an integrated approach to treatment, with the goal of restoring stability and function to the injured knee.
A posterior shoulder surgical approach combines the subperiosteal detachment of the deltoid from the scapular spine, described by McWhorter, with a lateral extension to include the lateral deltoid splitting of Codman. The glenohumeral joint is superiorly approached between the supraspinatus and infraspinatus tendons, or inferiorly between the infraspinatus and teres minor tendons. This approach was used in 42 shoulders with rotator cuff tears or posterior instability without complications of infection, failure of deltoid healing, or compromise of suprascapular or axillary nerves. This combined surgical approach provides excellent exposure of the superior and posterior shoulder, which is difficult to obtain by anterior or superior approaches. This approach may be used for repair of rotator cuff tears, posterior instability, and displaced posterior glenoid fractures.
Explore the source record for details and available documents.
We reviewed the clinical records and operative notes of seventeen consecutive patients who were treated by surgical repair for acute posterolateral rotatory instability in order to determine the diagnostic features of the instability and the effectiveness of our surgical repair in thirteen patients who returned for objective and subjective evaluation after a mean follow-up of 53.3 months. Sixteen of the seventeen knees had a positive external-rotation recurvatum test; fifteen, a positive adduction-stress test at 30 degrees of knee flexion; and twelve, a positive posterolateral-drawer test. Associated rotatory instabilities were found in ten of the seventeen knees, with anterolateral rotatory instability being the most frequent. Two patients had associated peroneal-nerve palsy. One or more components of the arcuate ligament complex were injured in all seventeen knees. None of the thirteen patients who were followed required subsequent reconstruction for any chronic instability. Of these thirteen, the results in 85 per cent were rated good subjectively and in 77 per cent, good objectively. Eighty-five per cent of these patients had returned to athletic activity at their preinjury level; the remaining 15 per cent did not participate in sports activities. A positive posterolateral-drawer test or external rotation recurvatum test, or both, was diagnostic of posterolateral rotatory instability. The adduction stress test at 30 degrees of knee flexion was usually positive, but was not diagnostic. Accurate diagnosis and treatment of posterolateral rotatory instability in the acute stage can result in subjectively and objectively acceptable knee function.
The posterior cruciate ligament, situated near the center of the knee, functions as the basic stabilizer and is located close to the axis of motion. We diagnosed and repaired thirty-two consecutive acute tears of the posterior cruciate ligament associated with tears of medial or lateral-compartment ligaments, or of both. Of the twenty-nine knees that we could evaluate, twenty-three demonstrated a 2+ to 3+ positive abduction or adduction stress test done in maximum extension and a positive anterior drawer test done in maximum internal rotation, while only nine had a definitely positive posterior drawer test. In all knees we repaired the tears, using the medial meniscus as a graft in nine knees in which the repair of the posterior cruciate ligament did not produce immediate adequate stability at operation. Five to sixteen years after operation, twenty of these twenty-nine knees were available for evaluation. The objective results were good in thirteen, fair in four, and poor in three.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
The functional anatomy of tha anterior cruciate ligament was studied in 18 freshly amputated specimens. The cruciates were observed in the extremes of flexion and extension, and in midposition in simulated weight-bearing and nonweight-bearing conditions. Five femoral shafts were split longitudinally so that the femoral and tibial attachments of the ligament could be inspected. The findings indicated that (1) the anterior cruciate ligament is a secondary static stabilizer against rotatory instabilities of the knee; (2) the anteromedial bundle contributes to anterolateral stability; (3) the intermediate bundle adds to straight and anteromedial stability; and (4) the posterolateral bundle assists in posterolateral stability. Specific bundles and functions of bundles must be considered in reconstruction, substitution, or replacement of the anterior cruciate ligament.
Disruption of the ulnar collateral ligament, flexor muscles, and anterior elbow capsule may result from valgus vector forces and subsequently cause difficulty in throwing, pulling, pushing and catching. Complete medial elbow tears were diagnosed acutely in four elbows by abduction stress tests at 15 degrees of flexion. Three elbows had associated ulnar nerve compression. We repaired torn medial structures by direct suture without ligamentous reconstruction. We also decompressed ulnar nerves and performed one anterior transposition. Full range of motion, strength, and return to previous functional level was attained without infection, neurovascular compression, or myositis ossificans.