The rotator cuff-deficient arthritic shoulder: diagnosis and surgical management

The symptomatic rotator cuff-deficient, arthritic glenohumeral joint poses a complex problem for the orthopaedic surgeon. Surgical management can be facilitated by classifying the disorder in one of three diagnostic categories: (1) rotator cuff-tear arthropathy, (2) rheumatoid arthritic shoulder with cuff deficiency, or (3) degenerative arthritic (osteoarthritic) shoulder with cuff deficiency. If it is not possible to repair the cuff defect, surgical management may include prosthetic arthroplasty, with the recognition that only limited goals are attainable, particularly with respect to strength and active motion. Glenohumeral arthrodesis is a salvage procedure when other surgical measures have failed. Arthrodesis is also indicated in patients with deltoid muscle deficiency. Humeral hemiarthroplasty avoids the complications of glenoid loosening and is an attractive alternative to arthrodesis, resection arthroplasty, and total shoulder arthroplasty. The functionally intact coracoacromial arch should be preserved to reduce the risk of anterosuperior subluxation. Care should be taken not to "overstuff" the gleno-humeral joint with a prosthetic component. In cases of significant internal rotation contracture, subscapularis lengthening is necessary to restore anterior and posterior rotator cuff balance. If the less stringent criteria of Neer's "limited goals" rehabilitation are followed, approximately 80% to 90% of patients treated with humeral hemiarthroplasty can have satisfactory results.     

Traumatic pulmonary hernia: surgical versus conservative management

B cells are characterized by the dual expression of CD40 and Fas receptors, which can mediate their survival and death, respectively. The balance between the dynamically opposing functions of these two receptors is important for B-cell selection, maturation and homeostasis. We found that mantle cell lymphoma (MCL) cells had a high level of CD40 and low or absent level of Fas, therefore favouring the CD40 cell survival pathway. Exogenous Fas ligand had no effect on MCL cells, whereas exogenous CD40 ligand enhanced their survival and rescued them from fludarabine-induced apoptosis. Our data raise the possibility that the prolonged survival of MCL cells in vivo may be explained by the unbalanced expression of Fas and CD40.     

Anterior shoulder instability. Current review

During the past several decades, the treatment of anterior shoulder instability has evolved substantially. Treatment initially was based on conservative management with rehabilitation protocols for shoulder girdle strengthening. Functionally disabling instability and recurrent dislocation precluded the acceptance of conservative management as the definitive treatment for all patients. Attention then was turned to open repair strategies. Despite generally positive results, a significant number of complications became evident. With time, however, techniques improved and surgical complications were lessened. As shoulder arthroscopy was more widely practiced, the surgical reconstruction of instability became significantly less invasive. A high learning curve has been associated with the new arthroscopic techniques, and higher redislocation rates than those of open procedures have limited their acceptance by many orthopaedic surgeons. This review article examines the anatomy and pathology of anterior shoulder dislocations, and critically reviews the actual laboratory and clinical data supporting use of these various treatment options. Only through careful examination of well-controlled scientific studies can clinicians devise their own treatment protocol for symptomatic anterior instability of the shoulder.     

Acute pancreatitis. Classification, diagnosis, therapy

Acute pancreatitis is a multietiologic entity with rather diverse clinical courses. Whereas edematous pancreatitis has a mortality of less than 1%, nowadays; still approximately 20% of all patients with the necrotizing form succumb to the disease. To further improve therapeutic results a standardized approach should be used. For effective treatment the differentiation between edematous and necrotizing pancreatitis is crucial. All patients with signs of pancreatic necroses during abdominal ultrasound and patients with organ insufficiencies should undergo a CT-scan to define exactly the nature and the extent of the disease. Primarily all patients are treated conservatively. Main indications for operative intervention are signs for infection of pancreatic necroses and an acute abdomen due to local complications of acute pancreatitis. In cases of biliary origin an elective cholecystectomy has to be performed during a free interval to prevent a recurrence.     

Arthroses of the hip joint and their treatment. Developments and progress in the area of conservative and surgical therapy

Osteoarthritis of the hip joint is due either to primary diseases of the articular cartilage or to secondary conditions leading to degenerative changes, for example, pre-arthritic deformities or arthropathies, so-called. Besides conservative treatment with non-steroidal anti-inflammatory drugs and physical therapy, treatment of pre-arthritic deformities by curative osteotomy continues to be of major importance. The introduction of the Rapid Prototyping method considerably improved the preoperative planning and orientation of such procedures. In the case of advanced coxarthrosis, total hip arthroplasty is used, in which, depending on bone biology, cementless procedures are now being employed in addition to the well-proven implantation with cement. Success depends not only on material and shape, but also to a high degree on the surface structure of these cementless implants. In particular three-dimensional interconnecting open-mesh surfaces enable differentiated anchoring of the prosthesis.     

Sacroiliac joint tuberculosis. Classification and treatment

The authors treated 16 patients with tuberculosis of the sacroiliac joint. Twelve were treated surgically and four were treated conservatively. The clinical symptoms were buttock and low back pain in all patients, and most had difficulty walking (68.6%) and had radicular pain in their lower limbs (50%). Of the 16 patients, four (15%) had associated tuberculous spondylitis, six (37.5%) had an abscess in the gluteal region, and two (12.5%) had an abscess in the inguinal region. The diagnosis was proven by pathologic specimen in 12 patients and by clinical symptoms, laboratory data, and radiologic findings in the remaining four patients. The authors classified tuberculous sacroiliitis into four types based on the clinical and radiologic findings. Types 1 and 2 were treated conservatively with chemotherapy alone, whereas Types 3 and 4 were treated with surgery and chemotherapy. Healing occurred and was evident in patients who had curettage and arthrodesis (Types 3 and 4) at a mean of 20.8 months, which was comparable with healing in the patients who had chemotherapy alone that occurred at a mean of 23.5 months (Types 1 and 2). The authors suggest that the new classification will be helpful in determining the therapeutic plan of tuberculous sacroiliitis.     

Weinert and Giachino ligament arthroplasty for the surgical treatment of chronic superior tibiofibular joint instability

This article describes a case of peripheral ossifying fibroma. The lesion is presented with respect to its clinical, radiographic, and histologic characteristics. Recommendations for proper diagnosis and treatment are suggested.     

Atraumatic shoulder instability. Discussion of classification and results after capsular imbrication

AIMS/BACKGROUND: We studied the fate of hepatocytes in the rat liver after D-galactosamine injury by genetic labeling using recombinant retroviruses carrying the Escherichia coli lacZ gene coupled to a nuclear localization signal. METHODS: Hepatocytes were either labeled by direct injection of 2.5 ml high-titer retrovirus-containing medium in the regenerating liver parenchyma after administration of a single dose of D-galactosamine. Alternatively hepatocytes were pre-labeled, 24 h after a two-thirds hepatectomy, by injecting the same volume of retroviral solution in the portal vein and D-galactosamine was administered 15 days later. Gamma-glutamyl transpeptidase and beta-galactosidase activities were assessed on cryostat sections, along with localization of the hepatocyte-specific HES6 antigen. RESULTS: Morphological observations, as well as beta-galactosidase activity detection, showed that hepatocytes actively divide as early as 1 day after D-galactosamine injection. Gamma-glutamyl transpeptidase activity was detected in biliary cells, but also in mature hepatocytes, pre-labeled with beta-galactosidase before D-galactosamine administration. CONCLUSIONS: These experiments demonstrate that hepatocytes can divide to restore the liver mass after D-galactosamine liver injury. Furthermore, we also show that gamma-glutamyl transpeptidase, which has been reported to be expressed only by fetal or preneoplastic hepatocytes, can be re-expressed by mature hepatocytes during the recovery process.     

Anal neoplasia. Pathogenesis, diagnosis, and management

Prolonged, severe immunodeficiency provides the necessary milieu for the emergence of anogenital neoplasia caused by human papillomaviruses. Anal neoplasia is likely to become a more common manifestation of HIV disease as patients with profound immunodeficiency, who would have succumbed to opportunistic infections earlier in the epidemic, are now surviving for extended periods of time because of increasingly effective antiretroviral, prophylactic, and antimicrobial therapies. The screening and treatment strategies described for use in HIV-infected patients with anal neoplasia are currently being investigated and refined.     

Anterior release test. A new test for occult shoulder instability

Occult shoulder instability is recognized as a significant contributor to shoulder dysfunction in throwing athletes. Diagnosis of occult instability by physical examination remains challenging. The anterior release test is a test for physical examination of the shoulder. It was developed to facilitate detection of occult anterior instability. One hundred shoulders were examined preoperatively by the same examiner. Based on surgical findings, the shoulders were classified as anterior instability or other. The results of examination were compared with the operative findings. Sensitivity was calculated as 91.9%, specificity 88.9%, positive predictive value 87.1%, negative predictive value 93.0%, and accuracy 90.2%. The anterior release test is a reliable and reproducible test for the detection of the unstable shoulder.     

Iatrogenic metatarsus primus elevatus. Etiology, evaluation, and surgical management

Iatrogenic metatarsus primus elevatus is an infrequent but devastating complication of first ray surgery. The authors address their clinical and radiographic evaluation of metatarsus primus elevatus, and describe a surgical treatment with emphasis on the sagittal plane Z-osteotomy. This osteotomy provides predictable and versatile correction for the treatment of iatrogenic deformities of the first metatarsal. It allows for plantarflexion and lengthening of the first metatarsal while avoiding an interpositional bone graft. The technical aspects of the procedure are thoroughly discussed.     

Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma

Traditionally radical hysterectomy has formed the mainstay of treatment for early stage cervical carcinoma. More recently radical trachelectomy and laparoscopic lymphadenectomy have been introduced to allow preservation of fertility. We present a new approach to fertility-sparing surgery, namely abdominal radical trachelectomy. The technique is similar to a standard radical hysterectomy and lymphadenectomy. In our technique the ovarian vessels are not ligated and, following lymphadenectomy and skeletonisation of the uterine arteries, the cervix, parametrium and vaginal cuff are excised. The residuum of the cervix is then sutured to the vagina and the uterine ateries re-anastomosed.     

Acute shoulder dislocation. Indications and techniques for operative management

The acute management of the initial, anterior shoulder dislocation is dependent on the age and activity demands of the patient. After a thorough examination and appropriate radiographs, a gentle closed reduction is the initial treatment. Previous authors have recommended a period of immobilization followed by a rehabilitation program emphasizing rotator cuff strengthening. Restricting return to athletic activities to allow adequate soft tissue healing is also recommended. This will effectively treat the vast majority of patients with this injury. In patients older than 25 years of age, one would expect a relatively low recurrence rate, especially in patients with low activity demands or in patients willing to modify activity. In active, young patients desiring a return to strenuous activity, however, most studies and our own experience demonstrate high recurrence rates. In the authors' experience, the examination under anesthesia and arthroscopic evaluation have confirmed an avulsion of the anterior-inferior capsulolabral complex as the primary injury component. The special circumstances of an initial dislocation with a hemarthrosis and excellent tissue quality make it ideal for arthroscopic stabilization. Our early results are encouraging and we believe this approach is a viable option in the management of this common injury in young athletes. As arthroscopic techniques for glenohumeral instability improve, we would expect an improvement on these initial results. Acute operative stabilization for the initial anterior dislocation is considered for: (1) initial dislocation that requires a reduction; (2) a young, athletic, high demand patient (<25 years of age) who is unwilling to modify his lifestyle; (3) subjects with no prior shoulder subluxation or impingement history; (4) subjects with no neurologic injury; and (5) subjects with no greater tuberosity fracture.     

Combined Bankart and HAGL lesion associated with anterior shoulder instability

Traumatic anterior shoulder instability has been shown to be associated with a spectrum of capsulolabral pathology, including separation of the labrum (Bankart lesion), capsular rupture, and humeral avulsion of the glenohumeral ligaments (HAGL lesion). We describe a case of combined Bankart and HAGL lesions, a condition that has not been described before. Careful anatomic repair of both components of this bipolar capsular injury resulted in an excellent outcome.     

Double outlet left ventricle. Morphology, cineangiocardiographic diagnosis and surgical treatment

In double outlet left ventricle,both the pulmonary artery and the aortaarisefromthemorphologicleft ventricle. This paper presents the anatomic and cineangiocardiographic features of five patients who had this condition proved at surgery or autopsy. The condition of the first patient was incorrectly diagnosed as transposition of the great arteries with pulmonary stenosis and ventricular septal defect; the anatomic features were correctly interpreted at operation in 1966 and appropriate repair was made, but the patient died postoperatively. The condition of the other four patients was correctly diagnosed. The second patient had Ebstein's malformation of the tricuspid valve and hypoplastic right ventricle in addition to double outlet left ventricle; her condition was not considered operable. Two patients, one with visceroatrial situs solitus, concordant d-loop and dextrocardia, were surgically treated with good long-term results. The fifth patient died 2 years postoperatively and is the first patient reported to have double outlet left ventricle with visceroatrial situs inversus, a discordant d-loop and levocardia. The segmental approach to the classification and diagnosis of connection disorders is discussed and the radiologic criteria by which double outlet left ventricle may be diagnosed considered in detail. The importance of using the radiologic projection (usually left anterior oblique) that profiles the ventricular septum is emphasized because the diagnosis can be established only by delineating the relations of the origins of the great arteries to the ventricular septum. The surgical significance of other anatomic features, including the number, size and position of ventricular septal defects and conal malformations, is also discussed.     

Decompression in the surgical management of degenerative spondylolisthesis: advantages of a conservative approach in 290 patients

The management of degenerative spondylolisthesis with laminectomy alone or laminectomy with fusion remains controversial. From the early 1970s to 1996, 290 patients with degenerative spondylolisthesis were treated with 249 laminectomies and 41 fenestration procedures over an average of 3.2 levels. One level olisthesis was encountered in 250 patients, and two levels of slip in 40. Patients averaged 67 years of age, and were followed an average of 10 years. Using Prolo's outcome scale, 69% of patients exhibited excellent, 13% good, 12% fair, and 6% poor outcomes. Secondary decompressions with fusions for increased olisthy/instability (five patients) and recurrent stenosis/disc disease/instability (three patients) required one posterolateral "in situ" fusion and seven Texas Scottish Rite Hospital instrumented procedures. Decompression alone successfully managed degenerative spondylolisthesis in 290 patients treated over 3 decades, because only 8 (2.7%) required secondary fusion.