Torn Capsule Research Articles

Irreparable Rotator Cuff Tears: A Biomechanical Comparison of Superior Capsuloligamentous Complex Reconstruction Techniques and an Interpositional Graft Technique.

Background:Irreparable rotator cuff tears lead to superior translation of the humeral head. Numerous surgical management options are available to treat the condition.Purpose:To compare superior capsule stability among different types of patch grafting in irreparable rotator cuff tears.Methods:Six cadaveric shoulders were tested in a custom-designed shoulder testing system. Superior translation of the humerus and subacromial contact pressure were quantified in an intact condition (condition 1), after cutting the supraspinatus tendon (condition 2), and after additionally cutting the superior capsuloligamentous complex (condition 3). The results were compared among 3 types of patch grafting, in which capsule reconstruction was achieved by glenoidal 3-point (condition 4) or 2-point (condition 5) fixation or by affixing a graft below the acromion (condition 6).Results:No significant difference in subacromial pressure was measured by reconstruction with 2 or 3 anchors compared with conditions 1 and 2 (P > .05). However, with 3-point fixation, lower levels of pressure were measured than with 2-point fixation. Moreover, superior translation values were lower with 3-point fixation; the same applied for values of the preserved capsule as compared with the torn capsule. In condition 6, a significant increase in pressure in the neutral position was documented (P < .05).Conclusion:The superior capsuloligamentous complex plays an important role in stabilizing the glenohumeral joint. The results suggest that with additional medial anchoring at the coracoid base, the depressing and centering effect of the superior complex can probably be regained in a more physiological way compared with a reconstructed capsule with 2 glenoid attachments or with an interpositional graft below the acromion.

Irreducible traumatic posterior hip dislocation with entrapment and a buttonhole effect

The authors reported the case of a 27-year-old man who sustained an irreducible postero-lateral traumatic dislocation of the hip with capsular and labral entrapment. Initial X-rays showed only a small acetabular fragment. After two attempts to reduce the hip with muscle paralysis under general anaesthesia failed, the patient was treated by immediate open reduction through a postero-lateral approach. Surgical exploration of the hip revealed a small osteochondral fragment attached to a large piece of labrum and capsule, clogging the acetabulum. The femoral head crossed over the torn capsule with a buttonhole effect. These elements were relieved, the bone fragment was fixed with a 2 mm screw and the capsule was repaired. At the 10-year follow-up, the functional outcome was excellent with a Harris score of 100 points and no signs of necrosis or osteoarthritis. The authors propose a literature review of this uncommon lesion.

뇌졸중 환자에서 재발성 턱관절 탈구의 관리 : 증례보고

Temporomandibular joint dislocation causes considerable pain, discomfort, and swelling. The anatomic construction of the articular fossa and the eminentia articularis may predispose to dislocation, and weakness of the connective tissue forming the capsule is believed to be a predisposing factor. The capsule may be stretched and, more rarely, torn. Dislocation may be unilateral or bilateral and may occur spontaneously after stretching of the mouth to its extreme open position, such as during a yawn or during a routine dental operation. Manual reduction with the patient under muscle-relaxing condition or anesthesia is recommended method. After the reduction of an acute dislocation, immobilization of the jaw is recommended to allow the stretched and sometimes torn capsule to heal, thus preventing recurrence. A Barton's bandage may be applied for 2 to 3 weeks to prevent the patient from opening the jaw too wide. But, it results in recurrent dislocation in the neurologically disabled patient, because of loose intermaxillary fixation. This is a case report about management of recurrent temporomandibular joint dislocation by multiple loop wirings and intermaxillary elastics in cerebrovascular accident patient.

Isolated thumb carpometacarpal joint dislocation: a case report and review of the literature

BackgroundIsolated thumb carpometacarpal dislocation is a rare injury pattern and the optimal treatment option is still controversial.Case DescriptionWe present a 27-year-old basketball player who underwent an isolated dorsal dislocation of the thumb carpometacarpal joint after a fall. The dislocation was successfully reduced by closed means but the joint was found to be grossly unstable. Due to inherent instability, repair of the ruptured dorsoradial ligament and joint capsule was performed.The ligament was detached from its proximal insertion into trapezium and subsequently stabilized via suture anchors. The torn capsule was repaired in an end-to-end fashion and immobilization of the joint was applied for 6 weeks.ResultsAt 3-year follow up evaluation the patient was pain free and returned to his previous level of activity. No restriction of carpometacrpal movements or residual instability was noticed. Radiographic examination showed normal joint alignment and no signs of subluxation or early osteoarthritis.ConclusionSurgical stabilization of the dorsal capsuloligamentous complex may be considered the selected treatment option in isolated carpometacarpal joint dislocations, that remain unstable after closed reduction in young and high demand patients.Level of Clinical Evidence: Level IV

Arthroscopic management of the postero-medial or postero-lateral capsule tear in the knee joint: technical note

We describe the arthroscopic management of the posterior capsule tear using posterior trans-septal portal. This technique is usually used in acute cases where a torn capsule is found but we can also use this technique for reefing of stretched capsule by refreshing the injured capsule. When arthroscopic ligament reconstruction accompanies postero-medial or postero-lateral capsular insufficiency, using the posterior trans-septal portal could ensure better visualization of the capsule and a subsequent more accurate management of the capsule. Since it is helpful in lessening the instability, it could contribute to achieving successful clinical results although this is not a mighty procedure.

Chopstick technique for nucleus removal in an impending dropped nucleus

We thank Lal and coauthors1 for sharing such an innovative technique in stabilizing an impending dropped nucleus. We hope the authors can further clarify several important issues pertaining to the daily practice of this technique. First, according to law of physics, if a disk-like structure such as the human nucleus is going to be firmly gripped with 2 tubular instruments such as the recommended Sinskey hooks, unless the resultant vector of forces acting on the 2 surfaces counteract each other exactly, rotational torques will be generated. In that case, the nucleus may be tilted or even flipped upside down in the torn capsule, causing further ripping of the capsule or dropping of the nucleus. We would like to know how to ensure that the Sinskey hook in the anterior chamber is in line with the Sinskey hook underneath the hard nucleus without proper endoillumination. Second, the posterior capsule tear may be extended farther and beyond salvage in this technique. The intraoperative photograph, Figure 3, shows clearly that the nucleus had been pushed to the nasal side. However, extension of the posterior capsule tear was not mentioned by the authors. A blind procedure underneath the nucleus may further damage the torn posterior capsule and paradoxically increase the risk for a dropped nucleus. Third, in an extreme scenario, such as a very soft nucleus, the pinching action of the 2 Sinskey hooks may prematurely trench or cheese-wire the nucleus and it may not be brought out in 1 piece, as anticipated. In the interest of readers, authors should share their view about this extreme scenario. The chopstick technique involves manipulation of a Sinskey hook in the body of the anterior vitreous before an anterior vitrectomy is performed. The Sinskey hook is designed to capture the intraocular lens eyelet. Manipulation of this 90-degree hook before vitrectomy can cause complications such as anterior vitreous capture or retinal tear or even detachment. Chang2 described the injection of Viscoat (sodium hyaluronate 3%−sodium chondroitin sulfate 4%) using a cannula via the pars plana route to levitate the nucleus, and Kelman3 used a metal spatula for manipulation in the posterior-assisted levitation technique. Blunt instruments such as a cannula or metal spatula are safer than the Sinskey hook because the undesirable effect of vitreous capture is minimized. Moreover, Shah and coauthors4 describe the use of a 25-gauge transconjunctival vitrectomy system for a pars plana anterior vitrectomy in the face of a posterior capsule rupture.4 Vitrectomy before manipulation of lens matter was recommended. In conclusion, we congratulate Lal and coauthors on their study describing the chopstick technique for nucleus removal. However, we would be interested to learn how the authors can avoid the above-mentioned difficulties and potential serious complications. David T.L. Liu MRCS Vincent Y.W. Lee FRCS Wai-Man Chan FRCP, FRCS Dennis S.C. Lam MD, FRCOphth Hong Kong, China

Reasons for failure after surgical repair of anterior shoulder instability

A total of 41 patients presenting with recurrent anterior instability of the shoulder after surgical repair were followed up after a mean period of 49 months (range, 24-81 months). The failed procedures were arthroscopic Bankart repair in 25 cases, open Bankart repair in 6 cases, Eden-Hybinette procedure in 4 cases, rotational osteotomy in 2 cases, capsular T- shift operation in 1 case, Bristow-Latarjet in one case, and a J-bone graft procedure in one case. In one case the index procedure was unknown. At revision surgery, the findings were a defect of the anterior bony glenoid rim in 23 patients (56%), a large capsule in 9 (22%), and a laterally torn capsule in 2 (5%). In 7 patients (17%) a typical Bankart lesion with good capsule quality was found. At revision surgery, these lesions were addressed by a bone graft procedure in 21 cases and fixation of the rim fragment with screws in 2 cases. In the 9 patients with a large capsule, a T-shift operation was performed in 6 and a Bankart repair with capsulorrhaphy was performed in the remaining 3. In the 7 patients with a typical Bankart lesion, a Bankart repair was performed, and in the 2 patients with a laterally torn capsule, an open suturing technique was used. At follow-up, none of the patients had had further redislocation or subluxation. The Rowe score was excellent in 81% of the cases and good in 19%. In 19 patients (46%) no increase in arthritic change was detected on radiographic assessment at follow-up, whereas 13 (32%) showed an increase of 1 degree and 4 (10%) showed an increase of 2 degrees. The results show that good and very good outcomes can be achieved with surgical repair provided that the basic pathology of the unstable shoulder is taken into account.

A CASE OF EXTRAMURALLY GROWING LEIOMYOSARCOMA OF THE STOMACH WITH INTRA-ABDOMINAL BLEEDING

A 72-year-old man was admitted to the hospital because of upper abdominal pain and abdominal full sensation. Gastrointestinal fiber revealed a gastric ulcer in the upper portion in the gastric body adjacent to the greater curvature. Abdominal CT showed the fluid collection in the upper abdomen and the tomor with the size of 8cm between the left lobe of the liver and spleen. Emergency operation was carried out with the diagnosis of intra-abdominal bleeding and tumor. Approximately 1L of hemorrhagic ascitis was noted, as well as the extramurally growing tumor in the upper portion of the gastric body adjacent to the greater curvature A total gastrectomy with lymph nodes dissection (D1) and ρ-Roux en Y anastomosis was performed. The resected material revealed that the tumor formed small ulcer on the gastric mucosa at the upper portion of gastric body adjacent to the greater curvature, mainly grooved extramurally, and a portion of the tumor destructed with torn capsule. It is uncommon that the disease presented with abdominal bleeding from the tumor. Pathological diagnosis was leiomyosarcoma of the stomach. It is difficult to diagnose the extramurally growing leiomyosarcoma of the stomach preoperatively. Reviewing the past reports of the extramurally growing leiomyosarcoma of the stomach presented with intraabdominal bleeding, clinicopathological features were investigated.

?It ain't over till it's over?

Catheterization and Cardiovascular Interventions 47:185 (1999) Editorial Comment “It Ain’t Over Till It’s Over’’ Jonathan M. Tobis, MD Division of Cardiology, UCI Medical Center, Orange, California As the great sage, Yogi Berra, predicted, sometimes complications occur even after a patient has left the catheterization laboratory. The accompanying case report by Verstraete et al. describes an unusual but potential risk associated with diagnostic intravascular ultrasound imaging. An intravascular ultrasound examination of the left coronary artery appeared to proceed smoothly and pro-vided helpful information to the operators in their decision to send this patient for bypass surgery. The operators visualized the torn capsule of a vulnerable plaque in the left main coronary artery. Passage of the ultrasound catheter presumably exacerbated the disrupted plaque with progression of thrombus despite heparinization and eventual occlusion of the left main coronary artery approximately 10 min after the patient left the catheterization laboratory. It is pertinent to note that the left main stenosis appeared worse on the angiogram obtained just prior to the ultrasound examination, suggesting that an active thrombus was present to account for such rapid progression. The operators were clearly trapped with a difficult clinical decision. The use of abciximab might have prevented the progression of the thrombus, but would have jeopardized the planned surgery. An alternative would have been immediate stenting; however, stenting left main disease is a high-risk procedure that many laboratories would not perform electively. After the patient suffered hemodynamic compromise, he was taken back to the laboratory where emergent stenting of the left main artery was successful. This case study serves as a useful way to remind all interventionalists that imaging with intravascular ultra-sound has potential risks. As the authors point out, the overall risk for severe complications is small. The most common complication associated with intravascular ultra-sound imaging is coronary artery spasm (,2%). This is easily reversible in most cases by removing the catheter and infusing intracoronary nitroglycerin. The only exception to this rule appears to be in transplanted hearts. These denervated arteries are more likely to go into spasm (,15%) and the degree of spasm is more intense than in nontransplanted hearts. Since these hearts do not transmit painful stimuli, the recognition of coronary artery spasm is discovered by angiography, intense ST elevation, or profound hypotension. Dissection of a coronary artery has been described but is an unusual complication of intravascular ultrasound imaging. The monorail IVUS catheter that uses a com-mon end hole for passage of either the guidewire or the ultrasound imaging core (2.9 Fr Clearview Ultracross Sci Med, Boston Scientific, Watertown, MA) has been associated with more trauma to the artery. This tends to occur when repositioning the guidewire out of the fixed tip of the catheter sheath. These complications have not been identified with the 3.2 Fr short monorail design or the current 2.6 Fr model (Discovery). The other area where trauma to the

Use of a Sheets' Glide as a Pseudoposterior Capsule in Phacoemulsification Complicated by Posterior Capsule Rupture

OBJECTIVE: To determine the safety and efficacy of using a Sheets' glide as a pseudo-posterior capsule to facilitate completion of phacoemulsification of the lens' nucleus following posterior capsule rupture during phaco. STUDY DESIGN: Intra- and postoperative review of Sheets' glide surgical technique used on five adult patients undergoing phacoemulsification who developed a posterior capsule rupture while the nucleus was still in the bag. SETTING: Norwood Clinic, outpatient ophthalmic department, Birmingham, Alabama, USA. MAIN OUTCOME MEASURES: Efficacy of Sheets' glide PC technique in management of this surgical complication. RESULTS: Each patient was successfully treated by manoeuvring the Sheets' glide to occlude the PC posteriorly, thus permitting completion of the removal of residual nucleus by phaco through a 5 to 6 mm scleral incision with an open posterior capsule. CONCLUSION: Although emulsification of the nucleus after PC rupture generally poses significant risk of loss of nuclear debris into the vitreous cavity, insertion of a Sheets' glide between the torn capsule and the nucleus may be safely and effectively used to act as a pseudo-posterior capsule to facilitate completion of the case using phacoemulsification.

A study of ankle instability utilizing ankle arthrography.

A preclinical and clinical study of ankle arthrography for chronic ankle instability was performed. In the first study, ankle arthrograms were done on 50 cadaver ankles to demonstrate the limits of the normal ankle joint, and it was demonstrated that contrast in tendon sheaths is not a sign of a torn ankle ligament. The second study consisted of investigating ten cases of chronic ankle instability utilizing ankle arthrography. It was concluded that ankle arthrography is helpful in diagnosing torn ankle ligaments if all remaining investigative procedures are negative. A positive ankle arthrogram is proof that a torn capsule and ligament has occurred. However, in this small series a negative a negative arthrogram and a normal talar tilt was still associated with a torn ligament of the ankle.

Periarthritis of the shoulder. II. Radiological features.

A group of 113 women and 73 men with periarthritis of the shoulder have been studied in detail. Electromyography showed 4 patients with neuralgic amyotrophy who had been referred for the shoulder study but were excluded on this basis. Nerve conduction studies showed little difference between the periarthritic group and a control group, apart from some reduction in amplitude and potential, and in women a suggestion of an increased latency. Duration of the action potential was equal. 6 patients had an undoubtedly long latency compatible with median nerve compression. Degenerative changes were found in the glenohumeral joints in 6-9%. Degenerative changes were found at the acromioclavicular joints in 31% of the men and 44% of the women. Calcification was found around 11 of the shoulder joints. There was frequently a previous history of 'rheumatism' before the episode of periarthritis. In one-third of the women 'nonspecific rheumatism' had occurred. Cervicobrachial pain and a previous episode of shoulder pain had occurred more often in the women. Arthrography was performed in 7 patients and there was a reduction in volume of material that could be injected in only one patient. There was obliteration of the axillary fold in that patient, and a torn capsule in a patient who had previously been manipulated. Lateral cervical spine x-rays were compared with films from an epidemiological survey. The disc space/vertebral body height ratio was taken, overcoming the magnification effects shown by technical alterations in the method of taking films. Good intra- and interobserver correlation was found for this ratio, but not for the width of the canal. There was no difference in the disc/body ratio between the periarthritic and control group in the upper cervical region. In the C5/6 and C6/7 intervertebral discs there was evidence of more disc degeneration in the periarthritic group. The differences from the control group were not great because of the high incidence of disc space narrowing and osteophytosis after the age of 45 years in the general population.

Subcapsular Rupture of the Kidney: Case Report

Injuries to the kidney may be graded according to the severity of the trauma: the following grades are recognised:—(a) Ecchymosis, (b) Sub-capsular rupture, (c) Total rupture. The usual methods of treatment are:— (i) Expectant treatment, where constitutional symptoms are absent and haematuria alone directs attention to the probability of a renal injury, and where intravenous and retrograde pyelography show no extravasation. (ii) Conservative surgery (tampon and suture) for a damaged kidney with a torn capsule. (iii) Nephrectomy for a destroyed kidney.

Tetra-Iodo-Phenolphthalein

In the March number of the British Journal of Radiology, there is an article by Dr. Dyas, D.M.R.E., on a case of “death coincident with the oral administration of sodium tetra-iodo-phenolphthalein.” The man, aged 62, had a very large liver and slight jaundice. He was given the “tetra” drug between 9 and 10 p.m., and X-rayed the following morning at 9—lying prone, with no compression ; and was apparently well when he left the X-ray department, but collapsed and died a few minutes after returning to the ward. P.M. intense portal cirrhosis present, extravasations of blood and torn capsule of the liver, acute degeneration of hepatic cells.

HABITUAL DISLOCATION OF THE SHOULDER

The literature on recurring dislocation of the shoulder has been reviewed recently by Henderson1and by Speed2and will not be repeated in this paper. In primary traumatic dislocation, the humeral head is thrust downward and forward, as the arm is hyperabducted. The capsule gives way along the margin of the glenoid rim between the subscapularis in front and the origin of the triceps on the posterior margin. From this position, the direction of force carries it forward beneath the coracoid process in 90 per cent of the cases. Recurrence of dislocation follows excessive function or accidental hyperabduction of the arm before the torn capsule has had sufficient time to heal. Each succeeding dislocation is accomplished with greater ease, and the capsule finally becomes patulous and accommodates the head outside the glenoid cavity. In a dissection of the anterior shoulder region three days after a recurring dislocation, I