Labral tears and acromioclavicular joint abnormalities were differentiated on physical examination using a new diagnostic test. The standing patient forward flexed the arm to 90 degrees with the elbow in full extension and then adducted the arm 10 degrees to 15 degrees medial to the sagittal plane of the body and internally rotated it so that the thumb pointed downward. The examiner, standing behind the patient, applied a uniform downward force to the arm. With the arm in the same position, the palm was then fully supinated and the maneuver was repeated. The test was considered positive if pain was elicited during the first maneuver, and was reduced or eliminated with the second. Pain localized to the acromioclavicular joint or "on top" was diagnostic of acromioclavicular joint abnormality, whereas pain or painful clicking described as "inside" the shoulder was considered indicative of labral abnormality. A prospective study was performed on 318 patients to determine the sensitivity, specificity, and positive and negative predictive values of the test. Fifty-three of 56 patients whose preoperative examinations indicated a labral tear had confirmed labral tears that were repaired at surgery. Fifty-five of 62 patients who had pain in the acromioclavicular joint and whose preoperative examinations indicated abnormalities in the joint had positive clinical, operative, or radiographic evidence of acromioclavicular injury. There were no false-negative results in either group.

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The standard surgical approach for repair or reconstruction of the ulnar collateral ligament of the elbow involves lifting off of the tendon of the common flexor bundle at its origin on the medial epicondyle. However, a more limited muscle-splitting approach may be feasible. A muscle-splitting approach is less traumatic to the flexor-pronator muscle mass, and it could decrease operative time and lessen immediate morbidity after surgery. A proposed muscle-split through the common flexor bundle extends from the medial humeral epicondyle to a point distal to the tubercle of the ulna such that repair or reconstruction can be performed on the ulnar collateral ligament. To examine the feasibility of this approach, we performed a study combining anatomic dissections with clinical observations. We dissected 15 fresh-frozen adult cadaveric elbows to examine the neuroanatomy of the medial side of the elbow. All pertinent nerves were identified and mapped. From these data, we defined a "safe zone" for a muscle-splitting approach to the ulnar collateral ligament that allows adequate room for repair or reconstruction of the ligament without risking denervation of the surrounding musculature. The safe zone extends from the medial humeral epicondyle to approximately 1 cm distal to the insertion of the ulnar collateral ligament on the tubercle of the ulna. Twenty-two patients with ulnar collateral ligament tears underwent either a direct repair or a reconstruction of the ligament using the proposed muscle-splitting approach. With a minimum followup of 1 year, there was no clinical evidence of muscle denervation. From the combined anatomic study and clinical data, we believe that a less traumatic muscle-splitting approach to the ulnar collateral ligament affords a safe and simple surgical approach for repair or reconstruction of the ligament.

Although the semitendinosus and gracilis tendons have long been used in ligamentous reconstruction procedures of the knee, their anatomic relationships have not been explicitly detailed. Therefore, cadaveric dissections were performed on fresh-frozen adult knees to examine these relationships. Several key anatomic points are useful in the harvest of these tendons. Their conjoined insertion site is medial and distal to the tibial tubercle. They become distinct structures at a point that is farther medial and slightly proximal. Tendon harvest is facilitated by identifying the tendons proximal to this point. The superficial medial collateral ligament lies deep to the tendons in this area and should not be disturbed. The tendons are ensheathed in a dense fascial layer that may impede tendon stripping. The accessory insertion of the semitendinosus tendon (which was present in 77% of the knees dissected) should be identified and transected to avoid tendon damage at harvest. Knee flexion may reduce the risk of injury to the saphenous nerve as it crosses the gracilis tendon. Variation in tendon diameter affects graft strength.