Extreme Abduction Research Articles

A review of the coracoclavicular joint: Description, etiology, and clinical significance.

The coracoclavicular joint (CCJ) is a synovial joint that forms between the conoid tubercle of the clavicle and the coracoid process of the scapula in approximately 2.5% of the population. The number of bilateral to unilateral cases is almost equal. The number of right-sided and left-sided cases is also almost equal. It is found in both males and females but most often in male adults. Very few cases have been identified in juveniles. Found in populations all over the world, the highest frequencies of CCJ are in Asia. The etiology is unknown but it is most likely caused by metaplastic change of the trapezoid and surrounding tissue due to compression and friction of the coracoacromial ligament between the clavicle and coracoid process. Typically asymptomatic, but if so, the most common complaint is anterior should pain exacerbated by extreme abduction. Successful treatment includes steroid injection and surgical excision.

Prediction of mechanical behavior of cartilaginous infant hips in pavlik harness: A subject-specific simulation study on normal and dysplastic hips.

In dysplastic infant hips undergoing abduction harness treatment, cartilage contact pressure is believed to have a role in therapeutic cartilage remodeling and also in the complication of femoral head avascular necrosis. To improve our understanding of the role of contact pressure in the remodeling and the complication, we modeled cartilage contact pressure in cartilaginous infant hips undergoing Pavlik harness treatment. In subject-specific finite element modeling, we simulated contact pressure of normal and dysplastic hips in Pavlik harness at 90° flexion and gravity-induced abduction angles of 40°, 60° and 80°. We demonstrated that morphologies of acetabulum and femoral head both affected contact pressure distributions. The simulations showed that in Pavlik harness, contact pressure was mainly distributed along anterior and posterior acetabulum, leaving the acetabular roof only lightly loaded (normal hip) or unloaded (dysplastic hip). From a mechanobiological perspective, these conditions may contribute to therapeutic remodeling of the joint in Pavlik harness. Furthermore, contact pressure increased with the angle of abduction, until at the extreme abduction angle (80°), the lateral femoral head also contacted the posterior acetabular edge. Contact pressure in this area could contribute to femoral head avascular necrosis by reducing flow in femoral head blood vessels. The contact pressure we simulated can plausibly account for both the therapeutic effects and main adverse effect of abduction harness treatment for developmental dysplasia of the hip. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

Treatment experience of proximal humerus degloving fracture

To summarize a new type of proximal humerus fracture-proximal humerus degloving fracture, and discuss its injury mechanism, classification criteria, and treatment methods. The clinical data of 23 patients with proximal humerus degloving fracture between September 2009 and September 2016 was retrospectively analyzed. There were 14 males and 9 females, with an average age of 39.7 years (range, 21-66 years). The causes of injury was sprain in 2 cases, falling from height in 8 cases, and traffic accident in 13 cases. The time from injury to operation was 3-116 days (mean, 17.1 days). There were 2 cases of posterior dislocation of humeral head, 3 cases of anterior dislocation of humeral head, 3 cases of other fractures, and 2 cases of brachial plexus injury. All patients had varying degrees of rotator cuff injuries. According to the self-determined fracture classification criteria, there were 6 cases of internal rotation type, 14 cases of external rotation type, and 3 cases of abduction type. All patients underwent open reduction and internal fixation. All patients were followed up 9-24 months (mean, 17 months). All incisions healed by the first intention. X-ray films showed that all fractures healed at 3-5 months after operation (mean, 3.6 months). According to the Neer's shoulder functional evaluation criteria at 6 months, the shoulder function was rated as excellent in 16 cases, good in 5 cases, fair in 1 case, and poor in 1 case, and the excellent and good rate was 84.6%. The rotator cuff tear recurred in 1 case and was repaired again. The injury mechanism of proximal humerus degloving fracture may be the extreme internal rotation, extreme external rotation, or extreme abduction. Reduction and internal fixation is an effective treatment. The focus of the treatment is not only the fixation of the fracture, but also the repair and reconstruction of the rotator cuff.

Hip Joint Contact Pressure Distribution During Pavlik Harness Treatment of an Infant Hip: A Patient-Specific Finite Element Model

Developmental dysplasia of the hip (DDH) in infants under 6 months of age is typically treated by the Pavlik harness (PH). During successful PH treatment, a subluxed/dislocated hip is spontaneously reduced into the acetabulum, and DDH undergoes self-correction. PH treatment may fail due to avascular necrosis (AVN) of the femoral head. An improved understanding of mechanical factors accounting for the success/failure of PH treatment may arise from investigating articular cartilage contact pressure (CCP) within a hip during treatment. In this study, CCP in a cartilaginous infant hip was investigated through patient-specific finite element (FE) modeling. We simulated CCP of the hip equilibrated at 90 deg flexion at abduction angles of 40 deg, 60 deg, and 80 deg. We found that CCP was predominantly distributed on the anterior and posterior acetabulum, leaving the superior acetabulum (mainly superolateral) unloaded. From a mechanobiological perspective, hypothesizing that excessive pressure inhibits growth, our results qualitatively predicted increased obliquity and deepening of the acetabulum under such CCP distribution. This is the desired and observed therapeutic effect in successful PH treatment. The results also demonstrated increase in CCP as abduction increased. In particular, the simulation predicted large magnitude and concentrated CCP on the posterior wall of the acetabulum and the adjacent lateral femoral head at extreme abduction (80 deg). This CCP on lateral femoral head may reduce blood flow in femoral head vessels and contribute to AVN. Hence, this study provides insight into biomechanical factors potentially responsible for PH treatment success and complications.

Developmental dysplasia of hip – An overview

Developmental dysplasia of the hip refers to a spectrum of severity ranging from mild acetabular dysplasia with a stable hip, to more severe forms of dysplasia with hip instability, to established hip dysplasia with or without subluxation or dislocation. DDH affects 1-3% of newborns and is responsible for 29% of primary hip replacements in people up to the age of 60 years. Ligamentous laxity is also believed to be associated with hip dysplasia, though this association is less clear. The treatment of DDH is age-related and the goal is to achieve and maintain concentric reduction of the femoral head into the acetabulum. A dislocated hip which can be reduced and a reduced hip that can be subluxated should be treated with the orthosis. All such hips should be treated in orthosis or harness beginning at the time of diagnosis. This results from excessive pressure on the femoral head after reduction in extreme abduction and internal rotation leading to vascular occlusion. Avascular necrosis results from excessive pressure on the femoral head after reduction in extreme abduction and internal rotation leading to vascular occlusion. Developmental dysplasia of the hip is a challenging condition. Formal training in the treatment of various age groups with DDH is mandatory. Successful treatment with Orthoses requires careful counselling of parents. Surgical management requires careful pre-operative planning and adequate follow up to ensure the best clinical outcomes.

Poster 250 Pain Relief for Plantar Fasciitis after Hydrodissection of Plantar Fascia from Pseudofascia: A Case Report

Disclosures: T. P. DeWald, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A right-hand-dominant 23-year-old male swimmer presented with persistent right shoulder pain, numbness, and paresthesia with radiation down the medial aspect of the right upper extremity. Patient stated that symptoms started gradually over a week and would only present during distances over 1,000 meters. Symptoms resolved when the athlete ceased activity. Setting: University Sports Medicine Clinic. Results or Clinical Course: Patient was treated conservatively with observation. Patient demonstrated normal physical examination. However, patient’s symptoms were reproduced with his right arm fully abducted and externally rotated and equivocal Adson’s test. Venous and arterial ultrasounds of the right upper extremity were obtained with no evidence of vessel obstruction. IR angiogram was then performed and did not show venous or arterial thoracic outlet syndrome. However, during provocative maneuver of extreme abduction and external rotation patient exhibited compression of the bilateral axillary arteries and circumflex humeral arteries. MRI of the right shoulder was negative for fat atrophy of teres minor and infraspinatus mucles. Electrodiagnostic studies did not demonstrate abnormalities in the axillary, ulnar, or median nerves with normal EMG of corresponding muscles. Patient resumed activity and continued to swim competitively with modification in training duration and regimen, demonstrating improvement in symptoms. The athlete will be evaluated for possible surgical decompression in the offseason. Discussion: Quadrilateral space syndrome is a rare condition arising from the compression of the axillary nerve and posterior circumflex humeral artery within the quadrilateral space. Ours is a unique case in which an athlete is demonstrating transient, ischemic quadrilateral space syndrome after long distance swimming. Muscle hypertrophy or fibrotic band formation have been implicated in pathology. Surgical decompression has proven to be successful in alleviating symptoms. Conclusions: Quadrilateral space syndrome should be considered as a differential diagnosis in young athletes with persistent shoulder pain and neuromuscular compromise as it can be missed.

Pelvis and Hip Three-Dimensional Kinematics in Grand Battement Movements

Dancers frequently sustain hip injuries, including labral tears, coxa saltans, stress fractures, tendinosis, and joint disease. High velocity kicks (grand battement), with extreme abduction and external rotation (ER), may stress the hip, sacroiliac joint, and surrounding soft tissue. However, three-dimensional kinematic dance descriptions are limited. The purpose of this study was to describe the kinematics of the pelvis and hip in grand battement movements in healthy dancers. Seventeen advanced-level college dancers performed three battement conditions: battement devant to the front, à la seconde to the side, and derrière to the back. Data were collected with a 5-camera motion capture system. Repeated measures ANOVA (p < 0.05) compared peak pelvis and hip angular displacement and hip and toe velocity for all conditions and planes. Three-dimensional hip to pelvic ratios were calculated. There were differences in pelvic angular displacement between conditions in all planes (p < 0.00). Battement devant posterior pelvic tilt exceeded that of battement seconde. Both were opposite in direction from the anterior pelvic tilt of battement derrière. All conditions demonstrated pelvic obliquity toward the stance limb, with battement derrière greater than devant and seconde. Battement derrière transverse plane pelvic displacement exceeded that found in devant and seconde. There were also differences in hip angular displacement between conditions in all planes (p < 0.00). Battement derrière hip extension differed from battement devant and seconde flexion. The hip abducted in all conditions, with battement seconde exceeding devant and derrière. In the transverse plane, the hip rotated internally in battement seconde and externally in battement derrière and devant. In battement devant and seconde, peak hip ER decreased relative to baseline, while increasing at the peak of battement derrière. Battement peak velocities were relatively low. The ratio of hip to pelvic angular sagittal plane motion was 4.1, 2.6, and 0.5 in battement devant, seconde, and derrière respectively; 0.9, 2.6, and 1.5 in the frontal plane; and 0.6, 8.5, and 0.2 in the transverse plane. This confirms that pelvic motion provides a large proportion of the battement movement.

Femoral Neuropathy: A Curse of Vaginal Hysterectomy

Cases: Two patients developed solitary unilateral peripheral femoral neuropathy after vaginal hysterectomy. Methods: Both were operated under spinal anesthesia in the lithotomy position. Straight rod leg supports with swing stirrups were used, and both of the procedures lasted for approximately 1½ hours. The complication is thought to be due to the extreme abduction of thighs with external rotation at the hip causing ischemia of the femoral nerve as it is kinked beneath the tough inguinal ligament. Conclusions: The prognosis was found to be excellent, with complete recovery within 8–10 weeks. The complication is preventable by using lateral thigh supports, limiting the degree of abduction. The pathophysiology contributing to this operative complication as well as measures for prevention and treatment are discussed. A personal observation and a literary review on femoral neuropathy after vaginal hysterectomy are presented. (J GYNECOL SURG 26:171)

Tecnología en salas de cirugía y neuropraxia del plexo braquial

Se presenta el caso de un paciente de 17 años, a quien se le realizó osteosíntesis de fémur por fractura de tercio medio secundaria a accidente de tránsito. En el postoperatorio, se encuentra debilidad e hipoestesia de miembro superior izquierdo, y se diagnostica neuropraxia del plexo braquial. Se identifica como factor desencadenante primordial la ubicación incorrecta del intensificador de imagen durante el transoperatorio, con abducción extrema de la extremidad. Se muestra la evolución y manejo del caso, se presenta una revisión sobre esta complicación perioperatoria y se dan al final unas recomendaciones para evitar la presentación de esta complicación This case refers to a 17-year old patient who underwent osteosynthesis of the femur due to middle third fracture following a traffic accident. During the post-op, the patient showed weakness and hypoesthesia of the upper left limb that lead to a diagnosis of brachial plexus neuropraxia. The underlying triggering factor identified was inadequate positioning of the image intensifier during the course of surgery, with extreme abduction of the limb. The evolution and management of the case is shown, together with a review about this perioperative complication.

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Background: Clinical understanding of normal glenohumeral ligament function is largely derived from in-vitro experimental observations, as little in-vivo data on glenohumeral joint kinematics and ligament function exists. Such information is relevant to understanding normal static restraints of the shoulder joint. Objective: To investigate humeral head translation and glenohumeral ligament function during in-vivo shoulder abduction with neutral, external and internal rotations. Study Design: In-vivo study using dual-orthogonal fluoroscopic system and magnetic resonance imaging (MRI). Methods: Five young and healthy living shoulders (2 left, 3 right; average age: 26 years) were investigated. Each subject underwent MRI scanning of the shoulder for the purpose of constructing a 3D anatomic shoulder model. In-vivo kinematics during active abduction from 0° to 90° and then combined with external and internal rotation of the abducted shoulder was captured using a dual-orthogonal fluoroscopy system. The in-vivo shoulder positions were then reproduced by matching the 3D shoulder model to dual-fluoroscopic images placed in a virtual fluoroscopic system built in a 3D solid modeling software. The origin and insertion of the superior, middle, anterior band and posterior band of the inferior glenohumeral ligaments (SGHL, MGHL, AB-IGHL, and PB-IGHL) were determined based on prior anatomic studies, and then used as a basis for the analysis of ligament length changes. Results: During abduction and rotation the humeral head translated more in the anterior-posterior direction (range: 6 mm) than the superior-inferior direction (range: 2.5 mm). Maximal elongation of the SGHL was observed at low abduction while the MGHL elongated the most above 45° of abduction and in a much larger range than the SGHL. The maximal elongation of the AB-IGHL was observed at high degrees of abduction with maximal external rotation, while the PB-IGHL was also maximally elongated at high degree of abduction, but with maximal internal rotation. Conclusion: This study shows that there is a large range of anterior-posterior translation during shoulder rotation, and thus not pure ball-in-socket motion suggested by prior experimental studies. Our observations show that the SGHL may only function to restrain the joint in low abduction angles while the MGHL likely functions at higher abduction angles, as having been reported in previous in-vitro studies. The AB-IGHL lengthens most with the arm in extreme abduction and external rotation, thus it is an important static restraint during the cocking phase of the throwing motion. The PB-IGHL plays a reciprocal functional role as it maximally lengthens when the shoulder is in maximum abduction and internal rotation. Clinical Relevance: These data further clarify the reciprocal relationship of glenohumeral ligaments as static restraints to excessive translations and rotations during in-vivo normal shoulder motion. The data is clinically relevant as restoration of normal motion is the goal of surgery for the unstable shoulder, and overconstraint during capsular shift procedures is possible if shoulder rotation is not taken into consideration when tightening each region of the capsule. If noted, the author indicates something of value received. The codes are identified as follows: a, research or institutional support; b, miscellaneous funding; c, royalties; d, stock options; e, consultant or employee. *The Food and Drug Administration has not cleared the drug and/or medical device for the use described in this presentation (ie, the drug or medical device is being discussed for an “off-label” use). If noted, the author indicates something of value received. The codes are identified as follows: a, research or institutional support; b, miscellaneous funding; c, royalties; d, stock options; e, consultant or employee. *The Food and Drug Administration has not cleared the drug and/or medical device for the use described in this presentation (ie, the drug or medical device is being discussed for an “off-label” use). If noted, the author indicates something of value received. The codes are identified as follows: a, research or institutional support; b, miscellaneous funding; c, royalties; d, stock options; e, consultant or employee. *The Food and Drug Administration has not cleared the drug and/or medical device for the use described in this presentation (ie, the drug or medical device is being discussed for an “off-label” use).

Traumatische Hemipelvektomie

With an incidence of only 0.6% of all pelvic injuries, traumatic hemipelvectomy is a rare event. It is defined as open or closed avulsion of one hemipelvis with occlusion or disruption of the main vessels and lengthening or disruption of the nerves, often complicated by urogenital or anorectal injuries. The mechanism of injury in this case is a typical one with extreme abduction and external rotation of the leg, causing sacroiliac joint disruption and symphysis separation. Two other mechanisms described are avulsion when the leg becomes entangled in a piece of machinery or a massive crushing at the groin. After a fast treatment in the field, the patient described was treated with immediate open revision, tamponade and stabilization of the pelvis. Upper leg preservation by reconstruction of the femoral vessels with vascular prostheses was attempted. Because of a broad necrosis of soft tissues, early completion of the hemipelvectomy was performed. The patient recovered well. Miction and bowel evacuation as well as sexual function could be preserved. The resulting quality of life is high and the patient is socially reintegrated without problems.

MRI of Internal Impingement of the Shoulder

Internal impingement is a condition that occurs in athletes in which the shoulder is put in extreme abduction and external rotation during overhead movements. During this motion, the posterior fibers of the supraspinatus tendon, anterior fibers of the infraspinatus tendon, or both can get impinged between the humeral head and the posterior glenoid. The purpose of this study was to evaluate the ability of MRI to show the findings of internal impingement of the shoulder. As opposed to our six patients with clinically and surgically diagnosed internal impingement, the control patients had isolated pathology in the rotator cuff, labrum, or humeral head. We found that the constellation of findings of undersurface tears of the supraspinatus or infraspinatus tendon and cystic changes in the posterior aspect of the humeral head associated with posterosuperior labral pathology is a consistent finding diagnostic of internal impingement.

Internal impingement in the etiology of rotator cuff tendinosis revisited

Purpose: The theory of internal impingement holds that, in overhead athletes, repeated contact between the undersurface of the rotator cuff and the posterosuperior glenoid rim leads to articular-sided partial-thickness rotator cuff tears and superior labral lesions. However, we have noted this same constellation of lesions in our general patient population. These recreational athletic patients do not routinely assume the position of extreme abduction and external rotation, and thus are unlikely to experience significant internal impingement forces. The goal of this study was to document the prevalence of superior labral lesions in patients being treated for partial-thickness undersurface rotator cuff tears. Type of Study: Retrospective case series. Methods: We retrospectively reviewed the records of 75 shoulders arthroscopically treated for partial-thickness articular-sided rotator cuff tears. With the exception of one professional tennis player, no patients were playing sports at a professional or major college level. No professional or collegiate throwing athletes were included. The prevalence of these lesions and their association with recreational athletics was noted. Results: We found that 55 of 75 (73.3%) shoulders with articular-sided partial-thickness rotator cuff tears also had superior labral lesions. A statistically significant increased prevalence of superior labral lesions in the dominant shoulder was seen ( P = .03). In addition, our patients who engaged in overhand throwing had significantly fewer superior labral lesions in the dominant shoulders than did nonthrowers ( P = .017). Conclusions: The “kissing lesions” of undersurface rotator cuff tears and posterosuperior labral damage may be explained by mechanisms other than “internal impingement.”

Anesthetic Considerations for Bariatric Surgery

According to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an increased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesityrelated conditions is based on body mass index (BMI), with 25–30 kg/m 2 being low risk and 40 kg/m 2 being very high risk (2). The prevalence of obesity in the 18- to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 (3). Bariatric surgery encompasses a variety of surgical weight loss procedures used to treat morbid obesity. Obesity is clinically expressed in terms of BMI or Quetelet’s index (4), which is derived by dividing weight by the square of height to estimate the degree of obesity. Thus, BMI body weight (kg)/height 2 (m 2 ). Morbid obesity is a BMI more than 35 kg/m 2 , and super morbid obesity is BMI more than 55 kg/m 2 . The indications for surgical treatment of severe obesity, as outlined in the 1991 National Institutes of Health Consensus Development Conference Panel, include an absolute BMI more than 40 kg/m 2 or BMI more than 35 kg/m 2 in combination with lifethreatening cardiopulmonary problems or severe diabetes mellitus (1). Patients seeking surgical weight loss must have proven attempts at medically supervised weight loss. Documentation of loss of 5% to 10% excess body weight or weight gain after at least 6 mo of diet modification, exercise, and medical therapy or nonimprovement in comorbid conditions during this period indicates failure. Studies have shown that weight loss of 5%–10% of initial body weight improves glucose intolerance and Type II diabetes, hypertension, and dyslipidemia (5–7). The average expenditure is approximately $7000 per year per patient on weight loss programs and equipment. Unfortunately, long-term weight loss is the exception, and most patients regain weight, sometimes more than they initially lost.

Preliminary traction and the use of under-thigh pillows to prevent avascular necrosis of the femoral head in Pavlik harness treatment of developmental dysplasia of the hip

One hundred and sixty-one hips of 145 patients were treated with the Pavlik harness for developmental dysplasia of the hip. The patients were divided into two groups. Group A consisted of 65 patients (70 hips) who were treated between 1980 and 1987. The harness was applied immediately after the diagnosis. Group B consisted of 80 patients (91 hips) who were treated between 1988 and 1992. These patients received preliminary traction, and small pillows supported the lower extremities from just above the knee to the foot to prevent extreme abduction when the harness was applied. When the distance from the middle point of the proximal metaphyseal border of the femur to the Y-line (distance “a”) was 8mm or more on the initial X-ray picture, the rate of avascular necrosis in group A was 11% and that in group B was 0%; the difference was significant. However, when distance “a” was less than 8mm, the rate of avascular necrosis in group A was 13% and that in group B was 12%, and there was no significant difference. Thus, we suggest that the Pavlik harness is indicated for developmental dysplasia of the hip in which distance “a” is 8mm or more. Traction should precede application of the harness, and pillows placed under the thigh must be used during application.

Suprascapular nerve rotator cuff compression syndrome in volleyball players

Selective denervation of the infraspinatus muscle producing weakness and wasting has been reported in certain sports (eg, volleyball and baseball). Nerve kinking or friction caused by excessive infraspinatus motion and compression by superior or inferior transverse scapular ligament or ganglions have been proposed as possible causes. However, in extreme abduction with full external rotation of the shoulder, the medial tendinous margin between the infraspinatus and supraspinatus muscles impinges strongly against the lateral edge of scapular spine, compressing the intervening infraspinatus branch of the suprascapular nerve. Spinoglenoid notchplasty has been performed in 5 elite volleyball players with infraspinatus neuropathy, allowing recovery of shoulder function in all patients and correction of infraspinatus muscle wasting. All returned to the same or higher level of volleyball by 8 months after surgery. An alternative cause of infraspinatus compromise in volleyball players is proposed and has been treated surgically with satisfactory outcome.

Congenital Fibrosis of the Extraocular Muscles Type 2, an Inherited Exotropic Strabismus Fixus, Maps to Distal 11q13

The extraocular fibrosis syndromes are congenital ocular-motility disorders that arise from dysfunction of the oculomotor, trochlear, and abducens nerves and/or the muscles that they innervate. Each is marked by a specific form of restrictive paralytic ophthalmoplegia with or without ptosis. Individuals with the classic form of congenital fibrosis of the extraocular muscles (CFEOM1) are born with bilateral ptosis and a restrictive infraductive external ophthalmoplegia. We previously demonstrated that CFEOM1 is caused by an autosomal dominant locus on chromosome 12 and results from a developmental absence of the superior division of the oculomotor nerve. We now have mapped a variant of CFEOM, exotropic strabismus fixus ("CFEOM2"). Affected individuals are born with bilateral ptosis and restrictive ophthalmoplegia with the globes "frozen" in extreme abduction. This autosomal recessive disorder is present in members of three consanguineous Saudi Arabian families. Genetic analysis of 70 individuals (20 affected individuals) reveals linkage to markers on chromosome 11q13, with a combined LOD score of 12.3 at the single nonrecombinant marker, D11S1314. The 2.5-cM CFEOM2 critical region is flanked by D11S4196/D11S4162 and D11S4184/1369. Two of the three families share a common disease-associated haplotype, suggesting a founder effect for CFEOM2. We hypothesize that CFEOM2 results from an analogous developmental defect to CFEOM1, one that affects both the superior and inferior divisions of the oculomotor nerve and their corresponding alpha motoneurons and extraocular muscles.

Bilateral femoral neuropathy after vaginal hysterectomy

A case of bilateral femoral neuropathy as a complication of vaginal hysterectomy is presented. A 45-year-old woman developed weakness of both quadriceps, absence of bilateral knee jerks, and numbness over bilateral anteromedial thighs and medial lower legs after a vaginal hysterectomy. Electromyographic examination revealed evidence of denervation in the bilateral quadriceps. A nerve conduction study showed prolonged distal latencies and markedly reduced amplitude of the compound muscle action potentials in bilateral femoral nerves. It is suggested that this complication is caused by a microvascular and/or local mechanical injury of the femoral nerve, which is compressed beneath the tough inguinal ligament in a sustained posture with the hip joint in an extreme abduction and external rotation position. The prognosis was excellent with almost complete recovery within 10 weeks. The complication may be preventable by minimizing operating time, changing the patient's posture, and limiting the degree of flexion, abduction, and external rotation of the hip.

Sports ability after Bankart procedure in professional athletes.

Recurrent anterior shoulder instability and the restoration of sports ability after surgery are common problems, especially among professional athletes. The purpose of this study was to evaluate the rate, level and time of returning to sports activity activity after Bankart procedure in anterior shoulder instability in high level athletes. From 1992-1994 61 patients suffering from recurrent anterior shoulder instability were operated on open Bankart procedure, 44 out of 61 were professional athletes. There were 7 handball, 7 basketball, 6 football, 2 waterpolo and 1 baseball player and 4 wrestlers, 2 weight-lifters, 2 boxers, 3 bicyclists, 2 motorists, 2 swimmers, 2 sailors, 2 kayakers and 2 skiers. The mean duration of instability was 19.1 months (3-72) before operation. 29 patients had posttraumatic recurrent anterior dislocation and 15 patients had posttraumatic anterior subluxations. The average number of redislocations was 4.4, ranging from 2 to 11. At the follow-up examination the patients were tested clinically for instability using the special score created by Walch and Duplay and the Constant functional score. We measured the strength of the rotator cuff by Kintrex isokinetic device from the 10th postoperative week. 35 out of 44 professional athletes could be followed-up. The average follow-up period was 14.2 months, from 6 to 31. 88% of the patients were able to return to sports participation, 66% on the previous level and 22% on a lower level. 12% of the patients finished their professional sports career. The mean rehabilitation period was 5.8 months, the average period of full restoration of sports ability was 9.3 months. Similar results were documented with the Constant score and the Walch-Duplay test (88% excellent or good, 12% fair). The main reason for the inability to continue sports activity was some pain during extreme abduction and external rotation of the arm and recurrent sensations of subluxation (3 cases). Based on the results of the follow-up examinations an early diagnosis is paramount followed by timely surgical intervention to restore anatomical integrity in proven cases of shoulder instability in professional athletes. The open Bankart procedure is preferred giving excellent functional results and providing good chances for the athletes to return to their previous sports level.

両側肩甲下部に発生した弾性線維腫の１例

Elastofibroma is a rare benign softtissue tumor characterized by the presence of elastic fibers among a stroma of collagenous and fatty connective tissue. This lesion occurs predominantly in the subscapular region.This paper presents a case of a 45-year-old male and a brief review of the literature.He was admitted to the Yoshida General Hospital because of bilateral tumors in the subscapular region which were only palpable at the inferior angle of the scapula when his arms were abducted.The tumors were elastic hard, semimobile, nontender and 10×8cm (right subscapular region), 3×2cm (left subscapular region) in size. The left-sided tumor coused no symptoms, while the right-sided tumor generated discomfort at extreme abduction of the patenlf right arm. Incision biopsy was performed on the right subscapular hinov, followed by local excision.