Objectives:Acromioclavicular (AC) joint injuries are common and constitute approximately 9% of all shoulder injuries. Traditionally Rockwood Types IV, V, and VI AC dislocations are indicated for surgery, type III dislocations are controversial, and type I and II are treated non-operatively. Our objective is to determine the success of non-operative treatment in Type V AC dislocations in active duty service members who must continue to do push-ups, pull-ups, bear weight, and wear ruck-sacks among other demanding activities requiring upper body strength in order to maintain current employment and lifestyle.Methods:A retrospective review was conducted using an automated search of electronic patient medical records from March 2007 through March 2012 for patients diagnosed with an AC dislocation in the Tripler Army Medical Center Department of Orthopedics. Patients were excluded who were not active military at the time of injury or who were tertiary referrals. Radiographs were reviewed and comparison was made to the contralateral shoulder. A Type V injury was defined as greater than 100% increase in the coracoclavicular distance compared to the contralateral side or greater than 2cm of displacement unilaterally. Acute repair was defined as repair within 90 days without a trial of conservative therapy. Failure of conservative therapy was defined as being unable to return to full duty. A good outcome was defined as a return to full duty without limitations.Results:103 patients were identified with 60 patients having a bilateral shoulder films. Normal CC distances of the uninjured shoulder ranged from 4.3 mm to 18.66 mm with a mean of 9.09 mm and a standard deviation of 2.30 mm. 34 patients were Type V dislocations. 5 patients were tertiary referrals and were excluded. Acute surgical AC reconstruction was selected in 8 patients, initial conservative therapy in 21. In the conservative group: 11 patients (61%) returned to duty without surgery (average 97.8 days); 5 patients had delayed surgery and returned to full duty (average 135.2 days after surgery, 1 revision); 1 was medically separated for this injury; 1 was considered a failure and elected to change his career; and 3 patients were lost to follow up. In the acute surgical group: 6 patients returned to full duty in an average of 169.3 days after surgery(mean time to surgery 28.29 days) with 3 of those requiring revision surgery; 1 patient was lost to follow up, 1 patient failed to return to full duty. In the conservatively treated group, there was no association between failure rates and increase in CC distance or mm of displacement (p= 0.32 and 0.69 respectively).Conclusion:While numerous studies have evaluated the operative versus non-operative treatment of type III injuries in both a prospective and retrospective manner, no study to date has reported on the conservative treatment of type V AC dislocations. In this study we report on conservative treatment being successful in a majority of patients and that the average time to return to duty was not improved in an a...
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A B S T R A C T.In a variety of circumstances, state governors exercise independent decisionmaking power over matters affecting the foreign policy of the United States. This Essay describes and defends this emerging system of gubernatorial foreign policy on both legal and functional grounds. Recent Supreme Court decisions retreating from federal exclusivity in foreign affairs and prohibiting the commandeering of state executive officials leave a small doctrinal space for governors to act independently on matters affecting foreign policy. This small space has been further expanded by the federal government's practice of imposing limitations on the preemptive effect of treaties and international agreements. A system of gubernatorial foreign policy also represents the most practical and feasible way to accommodate the internationalizing pressure of globalization with a continuing federal system of "dual sovereignties." Under this system, the states will continue to improve their capacity to deal with matters affecting foreign affairs, and the federal government will retain the right to preempt, but not to commandeer, state governors in the service of federal foreign policy goals.
For almost a quarter century, courts and judges, government officials and law professors have argued over the place of international law within the American legal system. Today, the "modern position" accepted by several courts of appeals and many leading international and foreign relations law scholars maintains that the federal courts can interpret and enforce customary international law (CIL) as federal common law. Incorporation of CIL as federal law formally occurs through the Alien Tort Statute (ATS), a previously obscure and largely ignored subsection of the Judiciary Act of 1789, whose text allows aliens to seek damages for torts in violation of the law of nations in federal court.' According to its supporters, the ATS allows the United States to play an important role in the development and enforcement of CIL generally, and human rights law specifically. 2
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