Journal of Shoulder and Elbow Surgery

The 11th International Congress on Shoulder and Elbow Surgery

Stephen Copeland — 2010-09-01

The 11th International Congress on Shoulder and Elbow Surgery (ICSES) and the 3rd International Congress of Shoulder and Elbow Therapists (ICSET) will take place in Edinburgh, Scotland, September 5th – 8th, 2010.

Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: A randomized clinical trial

Nicholas A. Ferran, Paul Hodgson, Nicola Vannet, Rhys Williams, Richard O. Evans — 2010-09-01

Background: Recent literature supports surgical intervention for shortened, displaced, mid-shaft clavicle fractures. We present the results of a randomized clinical trial comparing locked intramedullary fixation and plate fixation for short, displaced, mid-shaft clavicle fractures.Materials and methods: Local ethical approval was obtained and power analysis and sample size calculations were performed prior to commencement. Patients randomized to 2 groups to be treated with either locked intramedullary fixation or plating. Patients regularly followed up to clinical and radiographic union. The primary outcome measure was the Constant score, secondary outcome measures included the Oxford shoulder score, union rate, and complication rates.Results: Seventeen patients were randomized to locked intramedullary fixation and 15 randomized to plating. Mean age was 29.3years. Mean follow-up was 12.4 months. There was no significant difference in either Constant scores (P = .365) or Oxford scores (P = .773). There was 100% union in both groups. In the intramedullary group, 1 case of soft tissue irritation settled after the pin removal; 1 pin backed out and was revised. Three superficial wound infections resulted in plate removal and 8 plates (53%) were removed.Discussion: Intramedullary fixation has the theoretical advantage of preserving the periosteal blood supply, but carries the morbidity of pin removal. Clavicle plates are not routinely removed but require greater exposure and may compromise periosteal blood supply.Conclusion: Both locked intramedullary fixation and plating produce good functional results; however, metalwork may need to be removed as a second procedure.

Bicipital groove morphology on MRI has no correlation to intra-articular biceps tendon pathology

Joseph A. Abboud, Arthur R. Bartolozzi, Benjamin J. Widmer, Philip M. DeMola — 2010-09-01

Background: Multiple authors have debated the contribution of intertubercular groove morphology to biceps tendon pathology. It has been proposed that the shallow groove, combined with the supertubercular ridge of Meyer, predisposes patients to bicipital disease. In this study we hypothesized that there would be a correlation between bicipital groove morphology and the intraoperative finding of biceps pathology.Methods: Seventy-five consecutive patients (average age of 63) undergoing arthroscopic rotator cuff repair surgery had their biceps tendons and intertubercular groove morphologies prospectively evaluated on closed MRI T1 axial cut images. The opening angle and medial wall angle of the bicipital groove was measured for each patient. At the time of surgery, the biceps tendon was classified as normal, inflamed, partially ruptured, or ruptured and the findings correlated to the bicipital groove measurements.Results: The average opening angle was 81° for normal biceps tendons and 77° for torn biceps tendons. The average medial wall angle was 47° for normal biceps tendons and 49° for torn biceps tendons. Using Chi-square analysis, we found no statistically significant correlation between the bicipital groove average opening angle and medial wall angle on MRI and intraoperative biceps tendon pathology.Conclusion: This study does not support any correlation between intraarticular biceps tendon pathology and bicipital groove morphology.

Positive outcomes with intra-articular glenohumeral injections are independent of accuracy

2010-07-26

Background: Shoulder pain is a common, costly, and recalcitrant affliction. One treatment for shoulder pain is intra-articular injection of corticosteroid. Clinical opinion is that injection guided by palpation is accurate and effective, and there is some evidence to support a positive effect of injection on pain. However, great controversy exists as to the accuracy of injection by palpation, whether or not accuracy is important, and what the effect is of accuracy on pain.Methods: We used a blinded, longitudinal observational design of effectiveness in an effort to determine the accuracy of intra-articular injections and the effect of that accuracy on pain and functional outcomes in patients with various shoulder pathologies.Results: Injection accuracy data were captured on 103 patients. Of the 103 blinded injections, 54 received injections that were identified by fluoroscopy as “in” the capsule, whereas 49 were identified as “outside” the capsule; an accuracy rate of 52.4%. In the 4-week follow up, regardless of group assignment or accuracy of the injection, patients improved significantly (P < .01) from pre- to post-injection. Improvement was typically over by 2.5 points in the Numeric Pain Rating Scale (NPRS) categories, over 8 points on the Short-Form McGill Pain Questionnaire (SFMPQ), and over by 13 points on the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH).Discussion: Our accuracy rate was within the range reported in the literature. Improvements in all subjects with regard to pain and self-reported function occurred even in light of a wide variance in subject duration of symptoms, multiple injectors with varied training, a blinded approach to injection, and multiple injection approaches.Conclusions: The accuracy of the injection does not appear to depend on the experience of the physician and may be irrelevant in treating shoulder pain of multiple origins.

Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability

Péter Nyiri, Árpád Illyés, Rita Kiss, Jenő Kiss — 2010-09-01

Hypothesis: This study compared the kinematic parameters and activity pattern of muscles around the glenohumeral joint in multidirectional instability (MDI) treated by only physiotherapy and by capsular shift and physiotherapy, before and after treatment, to test the hypothesis that the surgery group would demonstrate better kinematic and muscle activity than the physiotherapy group.Materials and methods: The study comprised 32 patients with MDI treated with only physiotherapy, 19 patients with MDI treated by capsular shift and physiotherapy, and 50 healthy shoulders as the control group. The investigated kinematic parameters were the range of humeral elevation in the scapular plane, the scapulothoracic and glenohumeral angle, the scapulothoracic and glenohumeral rhythms, and relative displacement between the rotational centers of the humerus and the scapula. The muscle activity was modeled by the on-off pattern of muscles around the shoulder.Results: Before treatment, increased relative displacement between the rotational centers of the scapula and the humerus and different regression lines were observed in MDI patients. The physiotherapy strengthened the muscles, but regression lines remained monolinear. Capsular shift and physiotherapy resulted in bilinear regression lines and normal relative displacement between the rotation center of scapula and humerus was restored. After surgery and physiotherapy the activity pattern of muscles was almost normal.Conclusion: The significant alterations in kinematic parameters in MDI patients cannot be completely normalized by physiotherapy only. After the capsular shift and postoperative physiotherapy, the bilinear regression lines (angulation at 60°), the normal relative displacement between the rotational centers of scapula and humerus, and the normal muscular activity pattern were restored to normal ranges and maintained for at least 4 years.

Quality of life and functional outcome after a 2-part proximal humeral fracture: A prospective cohort study on 50 patients treated with a locking plate

Per Olerud, Leif Ahrengart, Anita Söderqvist, Jenny Saving, Jan Tidermark — 2010-03-22

Background: The aim of the study was to report the 2-year outcome after a displaced 2-part fracture of the proximal humerus in elderly patients treated with a locking plate, including an assessment of the health-related quality of life (HRQoL).Material and methods: We included 50 patients, mean age 75 (range, 55-93) years with 80% women. The fracture inclusion criteria were a displacement of the shaft of >50% of its width and/or >45° of angulation. Follow-up examinations were performed at 4, 12, and 24 months. The main outcome measures were the Constant and DASH scores and HRQoL according to the EQ-5D.Results: Eight patients (16%) were re-operated upon during the study period. At the final follow-up the mean Constant score was 61 and the mean DASH score 32. The EQ-5D index score decreased from 0.86 before the fracture to 0.62 at 4 months. At 12 months the EQ-5D index score was 0.65 and at 24 months 0.68. The values at all follow-ups were significantly lower than before the fracture (P < .001 in all 3 comparisons).Conclusion: Locking plates appear to be a good treatment alternative in elderly patients with a displaced 2-part fracture of the surgical neck of the proximal humerus with an acceptable complication rate and an acceptable functional outcome; however, rigorous attention has to be paid to avoid screw penetration. Despite the overall acceptable functional outcome, the patients reported a substantial negative effect upon their HRQoL.

The effect of medical comorbidity on self-reported shoulder-specific health related quality of life in patients with shoulder disease

James D. Wylie, Boris Bershadsky, Joseph P. Iannotti — 2010-03-22

Background: The purpose of this study was to investigate further the effect of medical comorbidity on a patient reported shoulder specific health related quality of life (HRQoL) measure. We investigated which types of comorbidities have a detrimental effect upon shoulder specific HRQoL. We hypothesized that general medical comorbidity would not negatively affect shoulder specific HRQoL questionnaires, but that comorbidities specific to the chest region would, when properly controlling for other patient factors.Methods: A cohort of 173 consecutive patients who underwent shoulder surgery for osteoarthritis and/or rotator cuff repair was extracted from a clinical outcomes database. Their health related quality of life (HRQoL) was evaluated with the University of Pennsylvania (PENN) shoulder score and the Short Form-36 (SF-36). Nonadjusted and multivariate risk-adjusted models were built to investigate the effect of medial comorbidity on shoulder specific HRQoL and were tested using linear modeling.Results: Nonadjusted models showed patients with more total comorbidities (P=.01) and more chest-related comorbidities (P=.006) had lower PENN scores. But, when risk adjusting for other patient factors, the PENN scores decreased with an increase in the number of chest comorbidities (P=.008), but not the number of total comorbidites (P=.391) or other (nonchest) comorbidities (P=.163).Conclusion: Shoulder specific HRQoL measures are joint specific, but they are influenced by disease or conditions that affect the chest region. This may be important in understanding why patients with certain comorbid diseases report worse shoulder pain and function and may respond differently to treatment over time.

Validation of the Dutch version of the Oxford Shoulder Score

Thomas Berendes, Peter Pilot, Jaap Willems, Hennie Verburg, Ron te Slaa — 2010-04-26

Background: The Oxford Shoulder Score (OSS) is an internationally-used patient-based outcome score. Up to now, it was not validated in Dutch. The purpose of this study was to produce a Dutch translation of the OSS and to test this version in terms of reliability and validity.Methods: Translation of the OSS was done according to the guidelines in literature. One hundred and three patients completed the Dutch version of the OSS. Additionally, the Constant-Murley shoulder score, the (Dutch) Simple Shoulder Test (DSST) score, and SF-36 were included into the validation process. Feasibility and patient-burden parameters were also tested.Results: One-hundred and three patients with general shoulder problems age 55 years (min-max: 21-81 ± 13yrs), sex ratio 2/3 (f/m) completed the Dutch version of the OSS and the SF-36. Internal consistency tested by the Cronbach's alpha (0.921) was high. Intra-class correlation coefficient was R = .981 (95% confidence interval: .961 – .993) and the mean difference between both tests was 2.7 points (0-8). Construct validity was also tested by the Pearson correlation coefficient and showed a significant correlation (P < .01) between the Dutch version of the OSS and the other scores (DSST 0.61; the Constant-Murley score 0.64 and with most of the SF-36 sub-scores, except for 2 psychometric subscales, namely, mental health (0.15 [P = .123]) and general health (0.10 [P = .316])Conclusion: The instrument proved to be valid by demonstrating significant correlations predicted by standard clinical assessments (DSST and Constant-Murley scores) and a generic patient-based instrument (SF-36). Application and evaluation in clinical trial proved feasible and understandable.

Surgical treatment of confirmed intratendinous rotator cuff tears: Retrospective analysis after an average of eight years of follow-up

2010-04-15

Hypothesis: This study evaluated clinical features, diagnostic techniques, and summarized the results of open repair in a series of surgically confirmed cases of intratendinous rotator cuff tears.Materials and methods: Between 1986 and 1999, 19 patients (17 men and 2 women) with intratendinous rotator cuff tears underwent surgery. Clinical findings, diagnostic results, and surgical findings were evaluated. The shoulder scores of the Japanese Orthopaedic Association (JOA) and the American Shoulder and Elbow Surgeons (ASES) were used to assess recovery at an average of 92 months (range, 31-231 months).Results: All patients had symptoms consistent with rotator cuff tendonitis. History of overt trauma was noted in 16 (84.2%). Neither ultrasound nor magnetic resonance imaging proved reliable for preoperative diagnosis. Surgery was performed if at least 6 months of conservative treatment, such as rest, heat, and physical therapies, failed. The definitive diagnosis was established intraoperatively with a longitudinal split along the fibers of the supraspinatus tendon. None of the intratendinous lesions had communication to the subacromial bursa or the glenohumeral joint. Excision of the intratendinous tear and repair resulted in improvement in pain and total scores of both JOA (66.8 vs 94.1) and ASES (37.1 vs 91.0).Conclusions: Intratendinous rotator cuff tears were difficult to diagnose preoperatively. Our data suggest that conservative treatment failed, anterior acromioplasty and excision of the diseased portion of the tendon, followed by tenorrhaphy, proved effective. Satisfactory outcomes were achieved in 18 patients (94.7%) in this series.

Results of a new stemless shoulder prosthesis: Radiologic proof of maintained fixation and stability after a minimum of three years' follow-up

2010-03-22

Hypothesis: In total shoulder arthroplasty, the humeral component, particularly the stem, can be involved in some of the complications and technical difficulties increase in posttraumatic arthritis with proximal humeral malunion. To decrease the intraoperative complications related to the stem, the TESS (Biomet Inc, Warsaw, IN) humeral implant, was designed in 2004 hypothesis that we can obtain a good fixation with a stemless prothesis. This investigation reports the preliminary results of this prosthesis with more than 3 years of follow-up.Methods: Between March 2004 and June 2005, 70 patients underwent 72 shoulder replacements with the TESS humeral prosthesis. Sixty-three patients were reviewed with a follow-up of more than 36 months (average, 45.2 months; range, 36-51 months). The mean preoperative Constant score was 29.6.Results: Gain in active mobility was 49° for forward flexion and 20° for external rotation. The postoperative Constant score was 75. Radiographic analysis showed no radiolucencies or implant migration. Functional results are comparable with previous reports on prosthetic glenohumeral replacement.Discussion: Our clinical results are similar to this with classical prosthesis. The humeral head removal facilitates the glenoid exposure and implantation. After the initial cases any specific complication was seen.Conclusions: Owing to the automatic central positioning of the implant, an anatomic reconstruction was achieved. In malunions, no tuberosity osteotomy was required. At 3 years of follow-up, there is radiologic evidence of maintained implant stability. These encouraging preliminary results confirm our belief that a stemless prosthesis can be used to obtain an anatomic reconstruction of the proximal humerus. A longer-term follow-up study is needed to validate these results.

Posterior shoulder instability secondary to reverse humeral avulsion of the glenohumeral ligament

Desmond J. Bokor, Brett A. Fritsch — 2010-04-26

Background: Posterior shoulder instability resulting from a disruption of the posterior capsular structures has been reported. We present the largest series of these injuries in the published literature, propose a definition and highlight the clinical presentation, radiological findings, and associated injuries.Materials and methods: A retrospective review of a single shoulder surgeons database was performed identifying posterior instability cases associated with disruption of the posterior capsule. Chart, radiological imaging, and intra-operative findings were reviewed.Results: Nineteen patients were identified with an average age lower than the overall posterior instability group. All occurred via a traumatic mechanism, the most common being a forced cross-body adduction. The only consistent symptom was posterior joint line pain. MRI reporting was found to be only 50% sensitive, increased to 78.6% when reviewed by the treating surgeon. Associated injuries are common with 58% having a labral tear, 32% a SLAP lesion, 26% a reverse Bankart lesion, 21% a chondral injury, 21% rotator cuff injury, and 11% extension of the tear into the posterior band of the inferior glenohumeral ligament.Discussion: Disruption of the posterior capsule is a rare cause of recurrent posterior instability. There are no specific symptoms that identify the injury, though a mechanism of forced cross-body adduction should raise suspicion. Identification of the injury requires specific attention to the posterior capsule on MRI, preferably performed with the arm in slight external rotation and routine visualization of the posterior capsule via viewing from the anterior portal.

Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: Prospective evaluation at a minimum two-year follow-up

Nicole A. Friel, Vasili Karas, Mark A. Slabaugh, Brian J. Cole — 2010-06-16

Hypothesis: Patients with type II superior labrum, anterior to posterior (SLAP) lesions will have improved function and decreased pain at a minimum of 2 years after arthroscopic SLAP repair using bioabsorbable suture anchor fixation.Materials and methods: The study population consisted of 48 patients who underwent arthroscopic SLAP repair. Subjective shoulder scores, range of motion, and strength (postoperative only) were assessed preoperatively and at a minimum of 2 years postoperatively.Results: At an average of 3.4 years after surgery, statistically significant improvement was seen in American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, Simple Shoulder Test scores, Constant activities of daily living, visual analog scale for pain, and Short Form-12 Health Survey physical outcome scores. Improvements were made in forward flexion, abduction, external rotation, and internal rotation. Subgroup analysis of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes showed preoperative to postoperative improvements in subjective outcomes scores. Overhead laborers and nonlaborers also showed preoperative to postoperative improvements in subjective shoulder scores.Discussion: No differences were seen between the outcomes of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes, suggesting that SLAP type II repair is successful independent of the patient's vocation or sport.Conclusion: These results show that arthroscopic SLAP repair of type II lesions with bioabsorbable suture anchors provides a significant improvement in functional capacity and pain relief.

Treatment of glenohumeral sepsis with a commercially produced antibiotic-impregnated cement spacer

Michael J. Coffey, Erin E. Ely, Lynn A. Crosby — 2010-04-15

Background: We report our experience in treating infected shoulder arthroplasty and primary shoulder sepsis using a commercially produced antibiotic-impregnated cement spacer.Materials and methods: We treated 16 shoulders in 15 patients for infected arthroplasty or osteomyelitis of the proximal humerus with irrigation and débridement, hardware removal, or humeral head resection, or both, and placement of an interval articulating hemiarthroplasty with a commercially made gentamicin-impregnated cement spacer.Results: Mean follow-up was 20.5 months after spacer placement. At the time of débridement, 12 shoulders had positive cultures; the most common organisms were methicillin-resistant Staphylococcus aureus (n = 3) and S. epidermidis (n = 3). Twelve patients underwent revision. Four refused revision and have retained antibiotic spacers. White blood cell counts returned to within normal ranges in all patients at the time of revision, the erythrocyte sedimentation rate in 5 of 12 patients, C-reactive protein in 8 of 12 patients, and interleukin-6 in 9 of 11 patients. Mean visual analog pain scale score decreased from 8.4 before spacer placement to 0.5 at the final follow-up. Active forward flexion increased from a mean of 65° to 110°, and active external rotation from –5° to 20°. Mean University of California Los Angeles (UCLA) Shoulder Rating Scale score increased from 7 to 26, Simple Shoulder Test (SST) from 1.2 to 6.6, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score from 16 to 74, and Constant score from 16 to 57. There was no recurrence of infection.Conclusions: Treatment of glenohumeral sepsis with a commercially produced antibiotic-impregnated cement spacer appears to be an effective treatment modality, and serum interleukin-6 level appears to be useful in the evaluation of shoulder infection.

Isokinetic testing of biceps strength and endurance in dominant versus nondominant upper extremities

Jocelyn Wittstein, Robin Queen, Alicia Abbey, Claude T. Moorman — 2010-04-09

Background: The strength and endurance of the contralateral biceps muscle can serve as a useful comparison for the operative limb following distal biceps repairs, mid-substance repairs, or tenotomy or tenodesis of the long head. There are limited data available on the effect of handedness on biceps strength and endurance.Hypothesis: The dominant upper extremity has greater elbow flexion and supination peak torque and endurance.Materials and methods: Subjects with no history of prior upper extremity injury or limitations completed isokinetic testing of biceps flexion and supination peak torque and endurance on a Biodex machine. A paired student t test was used to compare peak torque and endurance for both supination and flexion for the dominant and nondominant upper extremities. The results were analyzed for the entire group, and for male and female subjects separately as well.Results: A power analysis revealed that 5 subjects were needed to achieve 80% power. Twenty subjects (10 male, 10 female) were tested. No significant difference was detected for peak torque or endurance for supination or flexion between the dominant and nondominant upper extremities. No difference was detected when the group was analyzed as a whole, nor when men and women were analyzed separately.Conclusions: The dominant and nondominant upper extremities demonstrate similar peak torque and endurance for supination and flexion. The normal contralateral upper extremity can be used as a matched control in the evaluation of post operative biceps isokinetic strength and endurance without adjusting results for handedness.

Biomechanical evaluation on tendon reinsertion by comparing trans-osseous suture and suture anchor at different stages of healing: Experimental study on rabbits

2010-06-16

Background: Through an experimental biomechanical study on rabbits, tendon reinsertion by means of trans-osseous suture on a spongy bone bed and suture anchor were evaluated comparatively at different phases of healing.Methods: Twenty-four New Zealand White rabbits were used: 2 as pilots, 4 as the control group, and 18 as the experimental group. These 18 animals underwent sectioning and reinsertion of the Achilles tendon bilaterally, using the technique of trans-osseous suture on 1 side and suture anchor on the other. All the pelvic limbs that underwent the procedure were then immobilized for 3 weeks. The experimental group was divided into 3 groups that were sacrificed, respectively, 3, 6, and 12 weeks later. The tendon-bone complex was subjected to biomechanical tests to evaluate the parameters of maximum strength, stiffness, and yield strength.Results: There was no statistically significant difference between the suture anchor group and the trans-osseous suture group, in relation to yield strength (3 weeks, P = .222; 6 weeks, P = .465; and 12 weeks, P = .200) or maximum strength (3 weeks, P = .222; 6 weeks, P = .076; and 12 weeks, P = .078). In relation to stiffness, the suture anchor group showed a statistically significant difference only at 3 weeks of healing (P = .032) over the trans-osseous suture group.Conclusion: The technique of suturing with an anchor was shown to be similar to the technique of trans-osseous suture for the studied parameters.

Electromyographic activity of selected scapular stabilizers during glenohumeral internal and external rotation contractions

2010-09-01

Hypothesis: An important synergistic relationship exists between the scapular stabilizers and the glenohumeral rotators. Information on the relative contribution of the scapular stabilizers to glenohumeral rotation would be useful for exercise prescription for overhead athletes and for patients with shoulder pathology. We hypothesized that the scapular stabilizers would be highly active during both maximal and submaximal internal and external rotation.Materials and methods: Eight healthy male volunteers (16 shoulders) performed internal and external glenohumeral rotation testing at maximal and submaximal intensities. They also performed a scapular retraction rowing exercise at maximal and submaximal levels. Electromyographic (EMG) signals were recorded from the infraspinatus, pectoralis major, serratus anterior, and middle trapezius. Values were compared among muscle groups, among individual muscles at different intensity levels, and among individual muscles at different points in the arc of motion.Results: For submaximal glenohumeral internal rotation, activity in the scapular stabilizers was not different (P = .1-.83) from activity in the internal rotator throughout the range of motion. For the initial two-thirds of maximal internal rotation, middle trapezius activity and pectoralis major activity were higher (P < .05) than serratus anterior activity. For submaximal external rotation, activity in the scapular stabilizers during the middle phase of the motion was higher (P < .05) than activity in the external rotators. For maximal external rotation these differences were present throughout the motion with middle trapezius activity exceeding 100% maximal voluntary contraction.Conclusions: The scapular stabilizers functioned at a similar or higher intensity than the glenohumeral rotators during internal and external rotation. This highlights the importance of training the scapular stabilizers in upper extremity athletes and in patients with shoulder pathology.

Characteristics of donor and host cells in the early remodeling process after transplant of Achilles tendon with and without live cells for the treatment of rotator cuff defect -what is the ideal graft for the treatment of massive rotator cuff defects?

2010-04-26

Purpose: We examined the characteristics of donor and host cells in the early remodeling process after transplant of Achilles tendon with and without live cells to repair rotator cuff defects. We also clarified which graft with or without live cells was superior in the early remodeling process.Materials and methods: Sprague-Dawley (SD) rats and green fluorescent protein (GFP) rats were used; they were divided into 3 groups: in group SD, the Achilles tendons of GFP rats were transplanted into the defects of SD rats; in group GFP, the Achilles tendons of SD rats were transplanted into GFP rats; in group GFP-Fr, frozen Achilles tendons of SD rats were transplanted into GFP rats. At 3 and 7 days after surgery, these sections were examined histologically and immunohistochemically with anti-heat shock protein (HSP) 47 and anti-macrophage antibodies.Results: Donor cells gradually decreased, but HSP47-positive donor cells were detected at 3 days in group SD. Host cells infiltrated into the graft from the surrounding tissue, and their numbers in groups SD and GFP gradually increased more significantly than in group GFP-Fr. Macrophages derived from the donor tissue were absent in all groups. The remodeling process of the frozen graft was slower than that in the case of the graft that was not frozen.Conclusion: These results demonstrate that live donor cells have a positive effect on the remodeling process. Therefore, autografts with live cells considered to be preferred to frozen allografts or synthetic materials without live cells for transplant for rotator cuff defects.

Three-dimensional volume-rendering computed tomography for measuring humeral version

2010-04-09

Hypothesis: Humeral version is highly variable in human beings. Accurate assessment of humeral version may allow for more anatomic reconstruction at shoulder arthroplasty. Two-dimensional (2D) computed tomography (CT) has been used to measure humeral version but has limitations of poor interobserver reproducibility and strict dependence on arm positioning during image acquisition. This study evaluated a new technique, 3-dimensional (3D) volume rendering, for measuring humeral version.Materials and methods: Eight dried human humerus specimens were included in the study. Gold standard measurements of humeral version were obtained by use of metallic beads and fluoroscopy. The specimens were then scanned at CT in 2 different positions, 1 neutral to the table and 1 angled at 20°. The image data sets were used to measure humeral version in each bone with both the standard 2D technique and the new 3D technique. Measurements were performed by 3 readers at 2 different time points. Readers were blinded to the gold standard results and each others' measurements.Results: For all readers, 3D measurements averaged within 4.3° of the gold standard. For 2 of the 3 readers, 3D measurements were more accurate than 2D measurements. For all 3 readers, intraobserver variability was better with the 3D technique. For all reader pairs, interobserver variability was better with the 3D technique.Conclusions: This study shows a 3D volume-rendering CT technique to measure humeral version accurately and consistently that is independent of patient positioning.

Anatomy of the superior glenohumeral ligament

2010-05-03

Background: The aim of the present study was to give a detailed, anatomical description of the superior glenohumeral ligament and its relationship with the neighbouring structures in the rotator interval.Method: Twenty-seven cadaveric shoulder specimens were dissected in fine detail to describe superior glenohumeral ligament and additional histologic examination was performed.Results: The superior glenohumeral ligament is a constant, gross anatomic structure that was present in all of twenty-seven investigated specimens. The fibers of the superior glenohumeral ligament could be divided into two groups – the oblique and direct fibers. The direct fibers of the superior glenohumeral ligament arise from the glenoid labrum, run parallel with the tendon of the long head of the biceps brachii towards the lesser tubercle, which they also partly insert onto. The rest of the direct fibers course into the bottom of the bicipital groove and bridge over it, forming the superior part of the transverse humeral ligament. The oblique fibers arise from the supraglenoid tubercle, run over the intraarticular part of the tendon of the long head of the biceps brachii and insert below the coracohumeral ligament into the humeral semicircular ligament.Conclusion: Due to its anatomic composition and tight connection with the neighboring articular structures, the superior glenohumeral ligament is involved in the stabilizing mechanisms of the intraarticular part of the tendon of the long head of the biceps brachii and plays an important role in the variety of clinical disorders that occur within the rotator interval.

Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial

Timothy F. Tyler, Gregory C. Thomas, Stephen J. Nicholas, Malachy P. McHugh — 2010-06-28

Backround: Isokinetic eccentric training of the wrist extensors has recently been shown to be effective in treating chronic lateral epicondylosis. However, isokinetic dynamometry is not widely available or practical for daily exercise prescription. Therefore, the objective of this study was to assess the efficacy of a novel eccentric wrist extensor exercise added to standard treatment for chronic lateral epicondylosis.Materials and methods: Twenty-one patients with chronic unilateral lateral epicondylosis were randomized into an eccentric training group (n = 11, 6 men, 5 women; age 47 ± 2 yr) and a Standard Treatment Group (n = 10, 4 men, 6 women; age 51 ± 4 yr). DASH questionnaire, VAS, tenderness measurement, and wrist and middle finger extension were recorded at baseline and after the treatment period.Results: Groups did not differ in terms of duration of symptoms (Eccentric 6 ± 2 mo vs Standard 8 ± 3 mos., P = .7), number of physical therapy visits (9 ± 2 vs 10 ± 2, P = .81) or duration of treatment (7.2 ± 0.8 wk vs 7.0 ± 0.6 wk, P = .69). Improvements in all dependent variables were greater for the Eccentric Group versus the Standard Treatment Group (percent improvement reported): DASH 76% vs 13%, P = .01; VAS 81% vs 22%, P = .002, tenderness 71% vs 5%, P = .003; strength (wrist and middle finger extension combined) 79% vs 15%, P = .011.Discussion: All outcome measures for chronic lateral epicondylosis were markedly improved with the addition of an eccentric wrist extensor exercise to standard physical therapy. This novel exercise, using an inexpensive rubber bar, provides a practical means of adding isolated eccentric training to the treatment of chronic lateral epicondylosis.

Instrumented Bone Preserving elbow prosthesis in rheumatoid arthritis: 2-8 year follow-up

IJdo V. Kleinlugtenbelt, Pieter A.G.M. Bakx, Jaap Huij — 2010-09-01

Background: The aim of this study was to analyze the clinical and radiological results of elbow arthroplasty using the instrumented Bone Preserving (iBP) elbow prosthesis, which is the 6th iteration of the Kudo prosthesis, in patients with rheumatoid arthritis.Methods: From December 1999 to August 2006, 20 total elbow replacements in 19 patients with rheumatoid arthritis were performed by 2 surgeons using the iBP. The humeral component is uncemented and the ulnar component cemented. There were 14 women and 5 men. The period of follow-up was 2-8 years, with a mean of 49 months. The mean age at time of operation was 62 years (range, 32-80). The Larsen grade and The Mayo Elbow Performance Score were used. Possible radiolucent lines or displacement of the components were evaluated yearly.Results: The preoperative radiographs showed that all of the involved elbows were in grade 3-5 with an average of 4.1. All patients had a poor elbow before operation. Two elbows were moderately unstable. Three complications occurred: 1 intraoperative fracture of the medial condyl, 1 postoperative dislocation, and 1 persistent sensory ulnar neuropathy. After surgery, at the last follow-up, 3 patients had fair results, 5 good, and 12 excellent. In 6 cases, radiographic loosening of the ulnar component was observed without any clinical symptoms; none around the humeral component.Conclusion: The iBP elbow prosthesis in patients with rheumatoid arthritis shows good to excellent clinical results, despite radiolucency around the cemented ulnar component in some cases.

Delayed treatment of elbow pain and dysfunction following Essex-Lopresti injury with metallic radial head replacement: A case series

2010-06-18

Background: Chronic longitudinal radioulnar dissociation has been associated with unpredictable and generally unfavorable outcomes. Metallic radial head replacement may address this treatment deficiency.Methods: Eight patients were treated with a metallic radial head replacement for chronic longitudinal radioulnar dissociation. The average treatment delay was 3.3 years. All eight patients were seen for a clinical and radiographic assessment.Results: Five of the 8 failed after a mean of 3 years (range, 1-5.7). Revision to bipolar metallic radial head replacement was successful in the short term in 2 of 3 that failed from aseptic loosening. One of 2 failures due to painful radiocapitellar arthritis was salvaged with a capitellar replacement.Discussion: Reconstruction for symptoms following an Essex-Lopresti injury remains problematic. A metalic radial head implant appears to be an effective adjunct, but not a perfect solution in all patients. Recognition of the negative impact of residual lateral ulnar collateral ligament laxity is an important observation and should be specifically addressed with the reconstructive procedure.Conclusion: Metallic monoblock radial head replacement did not reliably address the functional deficiency from chronic radioulnar dissociation primarily due to malalignment and implant loosening. A cemented bipolar radial head implant may provide a better alternative as a long-term solution. Regardless, ligamentous integrity at the elbow should also be addressed at the time of the reconstruction.

Rotator cuff tears with cervical radiculopathy

Steven J. Hattrup, Robert H. Cofield — 2010-09-01

Shoulder pain is commonly attributed to rotator cuff tears, with an estimated 4.5 million US physician visits in 2002 for cuff problems. Although the tear may be treated conservatively at times, surgical repair is also a treatment option. The timing of such surgery and a reasonable estimation of the chances of success of such surgery are important considerations for the surgeon and patient. Shoulder pain can also be produced by an extrinsic cause such as cervical radiculopathy. Such a source of pain can coexist with a rotator cuff tear and have some influence on the treatment process for the cuff tear. The purpose of this review is to examine the overlap of these 2 problems and their interactions.

Glenohumeral chondrolysis: A systematic review of 100 cases from the English language literature

2010-04-26

Hypothesis: Chondrolysis can be a devastating complication of shoulder arthroscopy. We undertook a review of the 100 cases reported in the English language to test the hypothesis that common factors could be identified and that the identification of these factors could suggest strategies for avoiding this complication.Materials and methods: We systematically reviewed the English language literature and identified 16 articles reporting 100 shoulders in which postsurgical glenohumeral chondrolysis had developed.Results: The average reported patient age was 27 ± 11 years at the time of surgery; 35 were women. The most common indications for surgery were instability (n = 68) and superior labrum anteroposterior lesions (n = 17). In 59 cases, chondrolysis was reported to be associated with the use of intra-articular pain pumps. The infusate was known to include bupivacaine in 50 shoulders and lidocaine in 2. Radiofrequency capsulorrhaphy was performed in 2 shoulders.Discussion: Fifty-nine percent of the reported cases of glenohumeral chondrolysis occurred with the combination of arthroscopic surgery and postarthroscopy infusion of local anesthetic. The arthroscopic operations observed with chondrolysis were not limited to stabilization procedures, and the infused anesthetic was not limited to bupivacaine.Conclusion: In that postoperative infusion of local anesthetic and radiofrequency may not be essential to the success of shoulder arthroscopy, surgeons may wish to consider the possible risks of their use.

Delayed onset of posterior interosseous nerve palsy after a nonanatomic routing of a distal biceps repair: A case report

2010-07-05

Rupture of the distal biceps tendon is an uncommon injury. Conservative management of distal biceps ruptures has been reported to lead to a loss of power and endurance in elbow flexion and forearm supination. Surgical repair using a single- or double-incision technique has been recommended by most authors to restore elbow flexion and supination strength, especially in young active patients. Injury to the posterior interosseous nerve (PIN) has been reported to be more common with the single-incision technique, whereas heterotopic ossification and synostosis of the proximal radioulnar joint has been reported to be more common with the double-incision technique. Cases have also been reported of tendon rerupture, reflex sympathetic dystrophy, and neurologic injury, including the median nerve, superficial sensory branch of the radial nerve, lateral antebrachial cutaneous nerve, and anterior interosseous nerve, as well as temporary and permanent deficits of the PIN.

Postsurgical glenohumeral anchor arthropathy treated with a fresh distal tibia allograft to the glenoid and a fresh allograft to the humeral head

Matthew T. Provencher, Lance E. LeClere, Neil Ghodadra, Daniel J. Solomon — 2010-06-16

The treatment of extensive glenoid chondral defects in young, active patients remains a challenge. Chondrolysis and extensive chondral defects of the glenohumeral joint in young patients have been reported after shoulder surgery and have been associated with the use of thermal capsulorrhaphy, intra-articular pain pumps, and implanted fixation devices, such as suture anchors. Prominent glenohumeral anchors have been implicated in the early development of postoperative glenohumeral degenerative changes. A proud implant may cause local wear on the glenoid and the humerus, contributing to chondral loss, decreased range of motion, mechanical symptoms, and pain.

Historical giant near-circumferential osteochondroma of the proximal humerus

M. Allagui, K. Amara, I. Aloui, M.F. Hamdi, M. Koubaa, A. Abid — 2010-07-26

Exostosis is the most common benign tumor that represents a cartilage-capped osseous protrusion on the external surface of a bone. It is derived from cartilaginous tissue of the physis, which is separated from the periphery of the growth plate during augmentation. Osteochondroma commonly occurs in the metaphyseal region of the long bones. Osteochondroma is preferentially located at the distal metaphysis of the femur and the proximal metaphysis of the tibia, which together represent 40% of the cases; the proximal metaphysis of the humerus represents the second site of predilection. The majority of osteochondromas are asymptomatic, but limitations of joint motion and local compression of neurovascular structures are described. We report a case of a giant osteochondroma of the proximal humerus with major limitation of adduction and rotational motion of the arm. Extensive resection was followed by humeral intramedullary nailing.

Subacute repair of latissimus dorsi tendon avulsion in the recreational athlete: Two-year outcomes of 2 cases

Efrem M. Cox, Scott D. McKay, Brian R. Wolf — 2010-07-26

An avulsion injury to the latissimus dorsi tendon is considered to be the result of forceful resisted adduction and/or extension of the arm and is an uncommon occurrence. There are a limited number of cases reported in the literature utilizing both conservative and operative treatments for latissimus dorsi tendon avulsions. Only 1 repair of a chronic latissimus injury has been reported. No reports exist for repairs accomplished in the sub-acute setting using a single incision technique. We defined sub-acute here as greater than 6 weeks post injury, in the manner described by Wolfe et al for pectoralis major injuries.

Nonunion of a first rib fracture causing thoracic outlet syndrome in a basketball player: A case report

2010-06-17

Fractures of the first rib occur infrequently in athletes. This report describes a basketball player with thoracic outlet syndrome (TOS) resulting from nonunion of a first rib fracture with a hypertropic callus. Conservative therapy had been ineffective for 1 year after the patient sustained the injury, and he had complained of numbness in the left upper extremity when his shoulder was in abduction and external rotation.

Use of a compression tumor implant with total elbow arthroplasty for traumatic distal humeral bone loss in a young woman

Jana M. Davis, R. Judd Robins, Spencer J. Frink, Damian M. Rispoli — 2010-07-26

Traumatic open fractures associated with loss of significant portions of osteochondral and diaphyseal bone present a difficult clinical and surgical problem. This injury pattern occurring around the elbow is also known as a “side-swipe” injury. For younger patients, open reduction and internal fixation with bone grafting or structural allograft reconstruction is currently the accepted standard of care for manageable defects. Management of high-energy distal humeral fractures with significant bony loss using endoprostheses has been previously described. Total elbow arthroplasty (TEA) can be considered as an alternative in massive articular and segmental loss and has been shown to be successful in the elderly patient. Longevity of TEA has been shown to be suboptimal, especially in the younger active patient, with loosening occurring primarily on the humeral side. Endoprosthetic reconstruction of femoral deficits with a loaded ingrowth coupling has been shown to be effective for reconstruction after sarcoma resection. We present a case in which the Compress System (CPS) implant (Biomet, Warsaw, IN) was used in the upper extremity and paired to a Discovery total elbow prosthesis (Biomet, Warsaw, IN) to take advantage of a compression interface for treatment of traumatic distal humeral bone loss in a young woman to potentially enhance long-term survival.

Erratum to “Total shoulder arthroplasty with an uncemented soft-metal-backed glenoid component” [J Shoulder Elbow Surg 2010;19(4):624-631]

Sandro F. Fucentese, John G. Costouros, Stefanie-Peggy Kühnel, Christian Gerber — 2010-07-26

In this article, no disclosure information was provided for the authors in the final published version. The disclosure information should be as follows: “Drs. Fucentese, Costouros and Kühnel note that they, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. Dr. Gerber has disclosed that he receives royalty payments from Zimmer Corporation.”

Editorial Board

2010-09-01

Sponsoring Societies

2010-09-01

Journal of Shoulder and Elbow Surgery

The 11th International Congress on Shoulder and Elbow Surgery

Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: A randomized clinical trial

Bicipital groove morphology on MRI has no correlation to intra-articular biceps tendon pathology

Positive outcomes with intra-articular glenohumeral injections are independent of accuracy

Intermediate biomechanical analysis of the effect of physiotherapy only compared with capsular shift and physiotherapy in multidirectional shoulder instability

Quality of life and functional outcome after a 2-part proximal humeral fracture: A prospective cohort study on 50 patients treated with a locking plate

The effect of medical comorbidity on self-reported shoulder-specific health related quality of life in patients with shoulder disease

Validation of the Dutch version of the Oxford Shoulder Score

Surgical treatment of confirmed intratendinous rotator cuff tears: Retrospective analysis after an average of eight years of follow-up

Results of a new stemless shoulder prosthesis: Radiologic proof of maintained fixation and stability after a minimum of three years' follow-up

Posterior shoulder instability secondary to reverse humeral avulsion of the glenohumeral ligament

Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: Prospective evaluation at a minimum two-year follow-up

Treatment of glenohumeral sepsis with a commercially produced antibiotic-impregnated cement spacer

Isokinetic testing of biceps strength and endurance in dominant versus nondominant upper extremities

Biomechanical evaluation on tendon reinsertion by comparing trans-osseous suture and suture anchor at different stages of healing: Experimental study on rabbits

Electromyographic activity of selected scapular stabilizers during glenohumeral internal and external rotation contractions

Characteristics of donor and host cells in the early remodeling process after transplant of Achilles tendon with and without live cells for the treatment of rotator cuff defect -what is the ideal graft for the treatment of massive rotator cuff defects?

Three-dimensional volume-rendering computed tomography for measuring humeral version

Anatomy of the superior glenohumeral ligament

Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: A prospective randomized trial

Instrumented Bone Preserving elbow prosthesis in rheumatoid arthritis: 2-8 year follow-up

Delayed treatment of elbow pain and dysfunction following Essex-Lopresti injury with metallic radial head replacement: A case series

Rotator cuff tears with cervical radiculopathy

Glenohumeral chondrolysis: A systematic review of 100 cases from the English language literature

Delayed onset of posterior interosseous nerve palsy after a nonanatomic routing of a distal biceps repair: A case report

Postsurgical glenohumeral anchor arthropathy treated with a fresh distal tibia allograft to the glenoid and a fresh allograft to the humeral head

Historical giant near-circumferential osteochondroma of the proximal humerus

Subacute repair of latissimus dorsi tendon avulsion in the recreational athlete: Two-year outcomes of 2 cases

Nonunion of a first rib fracture causing thoracic outlet syndrome in a basketball player: A case report

Use of a compression tumor implant with total elbow arthroplasty for traumatic distal humeral bone loss in a young woman

Erratum to “Total shoulder arthroplasty with an uncemented soft-metal-backed glenoid component” [J Shoulder Elbow Surg 2010;19(4):624-631]

Editorial Board

Sponsoring Societies

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