Journal of Shoulder and Elbow Surgery

Editor's note

William J. Mallon — 2012-05-01

The Journal of Shoulder and Elbow Surgery (JSES) recently accepted an article, “Western Ontario Osteoarthritis Shoulder Index (WOOS): A Cross-cultural Adaptation into Swedish Including Evaluation of Reliability, Validity, and Responsiveness in Patients with Subacromial Pain,” one of a recent number of articles we have accepted looking at the validity of various scoring tests when translated into other languages.

Radius morphology and its effects on rotation with contoured and noncontoured plating of the proximal radius

Shavantha L. Rupasinghe, Peter C. Poon — 2011-06-27

Background: The radius has a sagittal bow and a coronal bow. Fractures are often treated with volar anterior plating. However, the sagittal bow is often overlooked when plating. This study looks at radial morphology and the effect of plating the proximal radius with straight plates and then contoured plates bowed in the sagittal plane. We report our findings and their effect on forearm rotation.Materials and methods: Morphology was investigated in 14 radii. Attention was paid to the proximal shaft of the radius and its sagittal bow; from this, 6-, 7-, and 8-hole plates were contoured to fit this bow. A simple transverse fracture was then made at the apex of this bow in 23 cadaver arms. Supination and pronation were compared when plating with a straight plate and a contoured plate. Ten cadavers underwent ulna plating at the same level. The effect on rotation of fractures plated in the distal-third shaft was also measured.Results: A significant reduction in rotation was found when a proximal radius fracture was plated with a straight plate compared with a contoured plate: 10.8°, 12.8°, and 21.7° for 6-, 7-, and 8-hole plates, respectively (P < .05). Forearm rotation was decreased further when a longer plate was used. Ulna or distal shaft plating did not reduce rotation.Conclusion: This study has shown a significant sagittal bow of the proximal shaft of the radius. Plating this with contoured plates in the sagittal plane improves rotation when compared with straight plates. Additional ulna plating is not a source of reduced forearm rotation.

Radial head translation measurement in healthy individuals: the radiocapitellar ratio

2011-07-04

Hypothesis: We hypothesized that the radiocapitellar ratio (RCR) is a valid and reproducible method to assess radial head translation in healthy individuals and that the normal RCR of healthy individuals is 0%.Materials and methods: Lateral radiographs of the elbow were examined in 40 healthy patients. The measurement method of the RCR was the displacement of the radial head (minimal distance between the right bisector of the radial head and the center of the capitellum) divided by the diameter of the capitellum. Intraobserver and interobserver reliability was evaluated using intraclass correlation (ICC).Results: The RCR was 4% ± 4% (range, −7% to 19%). The mean RCR of 4% measured in this cohort represents an anterior displacement of 1 mm in a capitellum of 25 mm. Intraobserver reliability was good (ICC, 0.72) and interobserver reliability was fair (ICC, 0.52). A significant side-to-side correlation was observed (r = 0.4, P = .009). No difference was identified between men and women, and no correlation was identified between age and the RCR. The standard deviation of the centered RCR measurements was 3%, which represented the variability of RCR measurements.Conclusions: The results of this study confirm the traditional belief that in the normal elbow, the radial head is generally aligned towards the capitellum on lateral radiographs. Accordingly, a RCR observed outside the ranges of 1 mm posterior (−5%) to 3 mm anterior (13%) in a 25 mm capitellum suggests a misalignment at the RC joint of the elbow. The RCR method to assess RC joint translations has demonstrated a normal distribution in healthy individuals and good reliability.

Implantation of a porcine acellular dermal graft in a primate model of rotator cuff repair

2011-07-04

Background: Non-cross-linked xenogeneic extracellular matrix graft materials have typically elicited a hypersensitivity reaction when implanted into humans or other primates. The purpose of this study was to examine the histologic and immune response to a non-cross-linked porcine-derived dermal extracellular matrix graft processed to remove the α-gal epitope.Materials and methods: Eight African green monkeys were implanted with porcine acellular dermal matrix (Conexa Reconstructive Tissue Matrix; Tornier Inc, Edina, MN, USA) to repair and augment a partial excision defect of the supraspinatus tendon of the rotator cuff. Four animals each were sacrificed at 3 months and 6 months, and histologic samples were compared with tissues harvested from unoperated shoulders.Results: Gross examination of grafted Conexa showed the appearance of integration proximally with tendon and distally with bone in each operated rotator cuff complex. Histologically, Conexa appeared to have remodeled to tendon-like architecture, with homogeneous distribution of fibroblast cells and parallel alignment of collagen fibers, with the direction of force evident by 3 months after implantation. Abundant vasculature observed at 3 months, which diminished to native tendon levels by 6 months, also indicated this to be a period of significant remodeling with an absence of significant inflammation, as evidenced by immunochemical methods and serum analysis.Conclusion: Conexa porcine acellular dermal matrix allows for incorporation of host tendon tissue without a hypersensitivity reaction in a primate model and should be a safe material for augmentation of human rotator cuff repair.

A watertight construct in arthroscopic rotator cuff repair

2011-07-22

Background: It is unknown which type of rotator cuff repair technique best isolates the healing zone interface from the synovial fluid environment. The purpose of this study was to determine the leakage area and pattern onto the rotator cuff footprint after 3 different rotator cuff repairs.Materials and methods: Six fresh frozen cadaveric glenohumeral joints in each of 3 groups were injected with gelatin to a pressure of 103 mm Hg (∼2 psi) after 1 of 3 different rotator cuff repairs of a supraspinatus tear: (1) single-row repair (SR), (2) knotless transosseous equivalent repair (KTE), and (3) traditional transosseous equivalent repair (TTE), which uses medial tied knots. Specimens were cycled in external rotation and abduction and were cooled to allow the gelatin to solidify. The supraspinatus was dissected off the footprint and photographs were taken. Scion Image (Frederick, MD, USA) was used to quantify the area.Results: The average area of leakage was 1.09 cm2 for the SR and 1.15 cm2 for the KTE. The TTE did not demonstrate any leakage. The pattern of leakage for the KTE was medial and central on the footprint, whereas the SR demonstrated leakage up to the tied knots. The difference in the area of leakage in the SR and KTE compared with the TTE was statistically significant. There was no difference in area of leakage between the SR and KTE.Conclusion: A transosseous equivalent repair technique best prevents leakage onto the rotator cuff footprint compared with single-row and knotless repairs.

Contrast-enhanced ultrasound characterization of the vascularity of the repaired rotator cuff tendon: short-term and intermediate-term follow-up

2011-07-25

Background: The objectives of this study were to characterize and compare the vascularity of arthroscopically repaired rotator cuff tendons at short-term and intermediate-term follow-up.Materials and methods: Nineteen patients who underwent arthroscopic rotator cuff repair were prospectively monitored for an average of 21.2 months. Initial baseline, grayscale ultrasound images of the operated-on shoulder were obtained on all patients at 3 months and at a minimum of 10 months postoperatively. Perflutren-lipid microsphere contrast (DEFINITY, Lantheus Medical Imaging, North Billerica, MA, USA) was injected after baseline grayscale images and after exercise to obtain contrast-enhanced images of the repair. Three regions of interest—supraspinatus tendon, peribursal tissue, and bone anchor site—were evaluated before and after rotator cuff-specific exercises.Results: The peribursal tissue demonstrated the greatest blood flow, followed by the bone anchor site and tendon, in pre-exercise and postexercise states. Significantly less blood flow was observed in all regions of interest before exercise (P < .05) and only at the bone anchor site after exercise (P < .001) at latest follow-up compared with the 3-month values. Intratendinous blood flow remained relatively low at both evaluation points after surgical repair.Conclusion: Preliminary findings suggest that the peribursal tissue and bone anchor site are the main conduits of blood flow for the rotator cuff tendon after arthroscopic repair, with the supraspinatus tendon being relatively avascular. Blood flow of the repaired rotator cuff tendon decreases with time. Furthermore, exercise significantly enhances blood flow to the repaired rotator cuff.

A pedicled bone graft from the acromion: an anatomical investigation regarding surgical feasibility

2011-07-04

Objective: To investigate the technical feasibility of harvesting a vascularized bone graft from the acromion pedicled on the acromial branch.Background: Complex fractures of the proximal humerus may result in partial or total avascular necrosis of the head fragment. Treatment of avascular necrosis of the humeral head is dependent upon the stage of disease as well as the dimension and location of necrosis. In general, the outcome is poor and complete restoration of the shoulder function is rarely attained. Contrary to osteonecrosis of carpal bones (where vascularized bone grafts have been routinely carried out for decades), reports of analogous procedures at the humeral head are anecdotal.Methods: Based on selective post-mortem computer-tomographic angiography of 5 and the dissection of 30 embalmed human cadaver shoulders, we describe the anatomy of the acromial branch of the thoracoacromial trunk. The main focus was the constancy of its anatomical course, its dimensions and potential use as a nutrient vessel for a pedicled bone graft from the acromion.Results: The course of the acromial branch revealed a constant topographic relationship to anatomical landmarks. Its terminal branches reliably supplied the anterior part of the acromion. The vascularized bone graft could be sufficiently mobilized to allow tension-free transfer to the humeral head as well as to the lateral two-thirds of the clavicle.Conclusion: We demonstrated the feasibility of vascularized bone graft harvesting from the acromion. This technique could be a joint-preserving procedure for osteonecrosis of the humeral head or may assist in the revision of a clavicular pseudoarthrosis.

A three-dimensional analysis of humeral head retroversion

Fraser Harrold, Carlos Wigderowitz — 2011-07-25

Introduction: The anatomic neck of the humerus is used as a reference for the osteotomy in shoulder arthroplasty. Resection along the anterior portion of the cartilage/metaphyseal border is assumed to remove a cap of a sphere that can accurately be replaced with a spherical prosthetic implant oriented precisely to the original articular surface. The aim of this study was to determine the variability in retroversion of the cartilage/metaphyseal interface in the axial plane.Methods: Surface topography data for 24 arms from deceased donors were collected by using a hand-held digitizer and a surface laser scanner. Data were combined into the same coordinate system and graphically presented. The humeral head was divided into 6 sections in the axial plane and the retroversion angle measured at each level with reference to the transepicondylar axis at the elbow.Results: The mean retroversion of the humeral head at the midpoint between the superior and inferior margins was 18.6°. The angle increased as the position of the measurement moved superiorly to 22.5°. In contrast, the retroversion angle reduced as the position of measurement moved more inferiorly to 14.3°.Discussion: The results suggest that the cartilage/metaphyseal interface is not circular encompassing a spherical cap of a sphere. Furthermore, there appears to be a clockwise torsion of the cartilage/metaphyseal interface about the transverse axis from its medial to lateral aspect.Conclusion: The cartilage/metaphyseal interface shows a degree of variability that makes it an unreliable landmark to perform an osteotomy when the anterior aspect of the interface is used.

Retrograde nailing versus locking plate osteosynthesis of proximal humeral fractures: a biomechanical study

2011-08-02

Background: In locking plate osteosynthesis of proximal humeral fractures, secondary varus malalignment is a specific complication. Retron nails (Tantum AG, Neumunster, Germany), among others, have been designed to improve medial support of the calcar humeri. The aim of our biomechanical study was to examine whether Retron nails provide increased stiffness for axial loads and adequate stiffness for torsional loads when compared with Philos plates (Synthes AG, Umkirch, Germany).Materials and methods: Twenty-two fresh-frozen paired humeri were collected. After potting the specimens, intact bones were exposed to sinusoidal axial (10-120 N) and torsional (±2.5 Nm) loading for 8 cycles to calculate the initial stiffness and exclude pairs with differences. Afterward, an unstable proximal humeral fracture (AO 11-A3) was created by means of an oscillating saw, and the respective osteosynthesis devices were implanted. After another 4 cycles, initial changes in stiffness were measured. Subsequently, all specimens were tested for 1,000 cycles of loading before final stiffness was assessed.Results: We found no statistically significant differences between Retron and Philos specimens after 4 or 1,000 cycles of loading.Conclusion: Our study suggests that retrograde nailing provides sufficient stability for axial and torsional loading in 2-part fractures of proximal humeri.

Voluntary activation deficits of the infraspinatus present as a consequence of pitching-induced fatigue

Jaipal Gandhi, Neal S. ElAttrache, Kenton R. Kaufman, Wendy J. Hurd — 2011-08-11

Hypothesis: Neuromuscular inhibition of the infraspinatus would be greater and external rotation muscle force would be lower after a simulated game compared with pregame values.Materials and methods: The sample included 21 uninjured, asymptomatic high school–aged baseball pitchers. Maximum volitional shoulder external rotation strength was assessed before and after a simulated game with a clinical dynamometer. Voluntary activation of the infraspinatus was assessed during strength testing by a modified burst superimposition technique. Performance-related fatigue was assessed by monitoring pitch velocity, and global fatigue was assessed by subject self-report before and after the game. Statistical testing included paired and independent t tests, with α ≤ .05.Results: There was no difference between throwing and non-throwing shoulder external rotation strength (P = .12) or voluntary infraspinatus activation (P = .27) before the game. After the game, voluntary activation was significantly lower in the throwing limb compared with pregame activation levels (P = .01). Lower external rotation strength after the game approached statistical significance (P = .06). Pitch velocity was lower in the final inning compared with first-inning velocity (P = .01), and fatigue was significantly greater after the game (P = .01).Conclusions: Voluntary infraspinatus muscle activation is a mechanism contributing to external rotation muscle weakness in the fatigued pitcher. Understanding mechanisms contributing to muscle weakness is necessary to develop effective injury prevention and rehabilitation programs. Treatment techniques that enhance neuromuscular activation may be a useful strategy for enhancing strength in this population.

Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation

2011-03-28

Background: Scapular dyskinesis is an abnormal scapular motion or position during active arm elevation. Dyskinesis is theorized to contribute to impingement syndrome by decreasing the subacromial space. A corrective maneuver of the scapular assistance test (SAT) proposes to increase scapular upward rotation and posterior tilt to increase the subacromial space. The purpose of this study is to determine the influence that 1) scapular dyskinesis and 2) passive manual correction with the SAT have on subacromial space and 3-dimensional (3-D) scapular kinematics.Materials and methods: Forty asymptomatic participants were classified with either obvious dyskinesis (n = 20) or normal motion (n = 20) using the scapular dyskinesis test. The anterior outlet of the subacromial space was measured via the acromiohumeral distance using ultrasound imaging and 3-D scapular orientation was assessed with electromagnetic motion analysis, with the arm at rest 45° and 90° of active elevation with and without the SAT, respectively.Results: There were no differences in acromiohumeral distance or scapular kinematics with static active arm elevation between groups. The SAT increased scapular upward rotation, posterior tilt, and acromiohumeral distance in both groups. Participants with dyskinesis demonstrated greater scapular mobility in upward rotation with the SAT, but no additional increase in acromiohumeral distance.Conclusion: Scapular dyskinesis identified during active motion did not result in different 3-D scapular orientation or acromiohumeral distance during active arm elevation in static positions; however, the SAT altered scapular kinematics and increased acromiohumeral distance. The SAT may be helpful to identify individuals where subacromial compression is producing symptoms, regardless of dyskinesis.

Inferior tilt of the glenoid component does not decrease scapular notching in reverse shoulder arthroplasty: results of a prospective randomized study

2011-11-14

Hypothesis: The purpose of this study was to determine if inferior tilt of the glenoid component decreased the amount of radiographic scapular notching after reverse shoulder arthroplasty. A secondary goal was to determine if inferior tilt had any effect on clinical outcome.Materials and methods: A prospective randomized trial of 52 consecutive reverse shoulder arthroplasties performed by 1 surgeon for cuff tear arthropathy was performed. The subjects were randomly assigned to receive a glenoid component with no inferior tilt (control group) or a glenoid component that was inferiorly tilted 10° to protect the inferior glenoid (inferior tilt group). All glenoid components were placed in 3 mm of inferior translation. Radiographic notching was graded at a minimum of 1 year after surgery. Clinical outcomes of the groups were recorded.Results: Follow-up radiographs and data were available for 42 subjects, 20 in the inferior tilt group and 22 in the control group. The experimental groups did not differ significantly in the notch ratings or clinical outcomes. Notching occurred in 15 patients (75%) in the inferior tilt group and in 19 (86%) in the control group. Notching scores were 2 or greater in 10 patients (50%) in the inferior tilt group and in 11 (50%) in the control group.Conclusion: Placing the glenoid component with inferior tilt does not reduce the incidence or severity of radiographic scapular notching after reverse shoulder arthroplasty. No clinical differences were observed between the groups.

The effect of capsular repair, bone block healing, and position on the results of the Bristow-Latarjet procedure (study III): long-term follow-up in 319 shoulders

Lennart Hovelius, Björn Sandström, Anders Olofsson, Olle Svensson, Hans Rahme — 2011-06-30

Background: We evaluated the results of the May modification of the Bristow-Latarjet procedure (“coracoid in standing position”) in 319 shoulders with respect to (1) coracoid healing and position and (2) surgical treatment of the joint capsule.Methods: From 1980 until 2004, all shoulders with a Bristow-Latarjet repair were registered at our hospital. This study consists of 3 different cohorts with respect to follow-up. Series 1, 118 shoulders operated on during 1980 through 1985, had 15 years’ radiographic and clinical follow-up. Series 2, 167 shoulders that had surgery during 1986 through 1999, underwent retrospective follow-up by a questionnaire and scores—Western Ontario Shoulder Instability Index; Disabilities of the Arm, Shoulder and Hand; and Subjective Shoulder Value—after 10 to 23 years. Series 3, 34 shoulders treated during 2000 through 2004, with an added modified Bankart repair (“capsulopexy”) in 33 shoulders, were prospectively followed up for 5 to 8 years with the same questionnaire and scores as series 2.Results: Of 319 shoulders, 16 (5%) had 1 or more redislocations and 3 of these (1%) had revision surgery because of remaining instability. One or more subluxations were reported in 41 shoulders (13%). The worst scores were found in 16 shoulders with 2 or more subluxations (P < .001). Radiographs showed bony healing in 246 of 297 shoulders (83%), fibrous union in 34 (13%), migration by 0.5 cm or more in 14 (5%), and no visualization in 3 (1%). Five of six shoulders that had the transplant positioned 1 cm or more medial to the glenoid rim had redislocations (83%, P = .001). Shoulders with migrated transplants did not differ from those with bony or fibrous healing with respect to redislocations and subluxations. When just a horizontal capsular shift was added to the transfer, the recurrence rate (redislocations or subluxations) decreased, with 2 of 53 (4%)compared with 37 of 208 (18%) with just anatomic closure of the capsule (P = .005), and the Western Ontario Shoulder Instability Index score improved (92 vs 85.6, P = .048). In total, for 307 of 319 shoulders (96%), patients were satisfied or very satisfied at final follow-up.Conclusion: The open Bristow-Latarjet procedure yields good and consistent results, with bony fusion of the coracoid in 83%. A position of the coracoid 1 cm or more medial to the rim meant significantly more recurrences. The rate of recurrences decreased and subjective results improved when a horizontal capsular shift was added to the coracoid transfer.

Do insurance and race represent independent predictors of undergoing total shoulder arthroplasty? A secondary data analysis of 3529 patients

2011-05-20

Hypothesis: Race and insurance status are independent predictors of the choice between total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) of the shoulder joint.Background: Current literature shows that ethnic and socioeconomic status may influence access to health care. However, no study has demonstrated whether insurance status and race are independent predictors that patients with glenohumeral osteoarthritis will undergo TSA.Materials and methods: Patients with primary International Classification of Diseases, 9th revision, Clinical Modification, procedure codes for TSA and HA were selected from the 1988 to 2007 United States Nationwide Inpatient Sample. Primary predictors were race (Caucasian, African American, Hispanic, other) and insurance status (private, Medicare, Medicaid, other). Multiple logistic regressions were used to determine whether insurance status and race were associated with the choice of procedure for patients presenting with glenohumeral osteoarthritis.Results: The study included data for 3529 patients, of whom 2369 underwent TSA (67.1%) and the remaining 1160 (32.9%) underwent HA. Of patients treated using TSA, 29% were privately insured, 63.2% had Medicare, and 2.5% had Medicaid (P < .001), and 62.1% were Caucasian, 2.5% were African American, 2.46% were Hispanic, and 30.9% had other ethnicities (P < .001).Discussion: Multiple logistic regression analysis found that privately insured patients and Medicare patients did not show statistically different odds of having TSA compared with patients within the Medicaid (reference category) or “other payment” categories, after adjustment for a variety of potential confounders. Caucasian patients also did not show statistically different chances of undergoing TSA compared with African Americans.Conclusions: We were unable to support statistical evidence that race and insurance status are independent factors associated with the choice of the surgical procedure in patients with glenohumeral osteoarthritis.

Polyethylene wear in retrieved reverse total shoulder components

2011-07-04

Background: Reverse total shoulder arthroplasty has been used to treat rotator cuff tear arthropathy and proximal humerus fractures, as well as for failed conventional total shoulder prostheses. It has been suggested that polyethylene wear is potentially higher in reverse shoulder replacements than in conventional shoulder replacements. The modes and degree of polyethylene wear have not been completely elucidated. The purpose of this study was to evaluate polyethylene wear patterns in 7 specimens retrieved at revision arthroplasty and identify factors that may be associated with increased wear.Methods: Reverse total shoulder components were retrieved from 7 patients during revision arthroplasty for loosening and/or pain. Preoperative glenoid tilt and placement and scapular notching were evaluated by use of preoperative radiographs. Polyethylene wear was evaluated via micro–computed tomography and optical microscopy.Results: Wear on the rim of the polyethylene humeral cup was identified on all retrieved components. The extent of rim wear varied from a penetration depth of 0.1 to 4.7 mm. We could not show a correlation between scapular notching and rim wear. However, rim wear was more extensive when the inferior screw had made contact with the liner. Metal-on-metal wear between the humeral component and the inferior screw of 1 component was also observed. Wear of the intended bearing surface was minimal.Discussion: Rim damage was the predominant cause of polyethylene wear in our retrieved specimens. Direct contact between the humeral component and inferior metaglene screws is concerning because this could lead to accelerated ultra-highmolecular weight polyethylene wear and also induce mechanical loosening of the glenoid component.

Total shoulder replacement surgery with custom glenoid implants for severe bone deficiency

Stephen B. Gunther, Tennyson L. Lynch — 2011-06-30

Background: Treatment of patients with shoulder arthritis and severe glenoid bone loss is controversial. Medial and posterior bone loss limits the size of the glenoid vault, which is the structural support of all current glenoid designs. This study presents short-term outcomes of a treatment using inset glenoid implants during shoulder replacement surgery in deficient glenoid bone.Methods: This study presents short-term outcomes of total shoulder replacement surgery using custom inset glenoid implants in deficient glenoid bone. Seven consecutive patients (3 men, 4 women; mean age 70 years) treated with inset glenoid implants for severe bone deficiency were retrospectively evaluated at a minimum 3-year follow-up. Severely deficient bone was defined by a neutral glenoid vault depth of less than 15 mm. No bone grafts were used. All patients were evaluated before and after surgery with physical examination, radiographic studies, and outcome measures. All patients had a diagnosis of osteoarthritis. No patients had rotator cuff tears or a history of instability.Results: No surgical complications occurred. At an average of 4.3 years, the mean American Shoulder and Elbow Surgeon score improved 68 points. There were statistically significant improvements in range of motion (forward flexion 33°, external rotation 34°, internal rotation 6 spinal levels) and in pain (6.9 to 0.1). Independent radiographic analysis determined all implants were classified as “low risk” for glenoid loosening.Discussion: The treatment of shoulder arthritis with severe glenoid bone loss is controversial and the results are mixed. Current treatments consist of hemiarthroplasty with or without glenoid reaming, total shoulder replacement without version correction, and total shoulder replacement with bulk bone grafting and version correction. The surgical technique and clinical results described in this case series demonstrate a novel approach of inset glenoid fixation for severely deficient bone.Conclusions: This study documents for the first time the possibility of safely and effectively using inset glenoid implants to reconstruct deficient bone for which standard implants are contraindicated.

Pectoralis major tendon transfer for the treatment of scapular winging due to long thoracic nerve palsy

2011-07-04

Background: Painful scapular winging due to chronic long thoracic nerve (LTN) palsy is a relatively rare disorder that can be difficult to treat. Pectoralis major tendon (PMT) transfer has been shown to be effective in relieving pain, improving cosmesis, and restoring function. However, the available body of literature consists of few, small-cohort studies, and more outcomes data are needed.Materials and methods: Outcomes of 26 consecutive patients with electromyelogram-confirmed LTN palsy who underwent direct (n = 4) or indirect transfer (n = 22) of the PMT for dynamic stabilization of the scapula were reviewed. All patients were followed up clinically for an average of 21.8 months (range, 3-62 months) with evaluations of active forward flexion, active external rotation, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and observation of scapular winging.Results: Preoperative to postoperative results included increases in the mean active forward flexion from 112° to 149° (P < .001) an in mean active external rotation from 53.8° to 62.8° (P = .045), an improvement in the mean ASES score from 28 to 67.0 (P < .001), and an improvement in the mean VAS pain score from 7.7 to 3.0 (P < .001). Recurrent scapular winging occurred in 5 patients. There was no difference in outcome by length of follow-up.Conclusions: PMT transfer is an effective treatment for painful scapular winging resulting from LTN palsy. This is the largest reported series of consecutive patients treated with PMT transfer for the correction of scapular winging.

Outcomes of tendon fractional lengthenings to improve shoulder function in patients with spastic hemiparesis

Surena Namdari, Hassan Alosh, Keith Baldwin, Samir Mehta, Mary Ann Keenan — 2011-06-30

Background: Patients with spastic hemiparesis after upper motor neuron (UMN) injury often exhibit limited shoulder movement. We evaluated the outcomes of shoulder tendon fractional lengthenings in patients with spasticity and preserved volitional control.Methods: A consecutive series of 34 adults with spastic hemiparesis from UMN injury (23 post-stroke, 11 post-traumatic brain injury) and limited shoulder movement with preserved volitional motor control who underwent shoulder tendon fractional lengthenings (pectoralis major, latissimus dorsi, teres major) were evaluated. Active and passive shoulder motion, spasticity, pain, and satisfaction were considered pre- and postoperatively.Results: There were 15 males and 19 females with a mean age of 44.1 years. Mean follow-up was 12.2 months. Mean Modified Ashworth spasticity score was 2.4 preoperatively compared to 1.9 postoperatively (P = .001). Active flexion, abduction, and external rotation improved compared to the normal contralateral side (P < .001) with most dramatic gains in external rotation. Similarly, passive extension, flexion, abduction, and external rotation improved compared to the normal contralateral side (P < .01). Ninety-four percent (15/16) with preoperative pain had improved pain relief postoperatively with 14 (88%) being pain-free. Thirty-one (92%) were satisfied with the outcome.Conclusion: Shoulder tendon lengthenings can be an effective means of pain-relief, improved motion, enhanced active motor function, and decreased spasticity in patients with spastic hemiparesis from UMN injury.

Small supraspinatus tears repaired by arthroscopy: are clinical results influenced by the integrity of the cuff after two years? Functional and anatomic results of forty-six consecutive cases

Omar Boughebri, Xavier Roussignol, Olivier Delattre, Jean Kany, Philippe Valenti — 2011-08-01

Purpose: We assessed cuff integrity after arthroscopic repair of small full-thickness supraspinatus tears (<2 cm) and the correlation with clinical results and predisposing factors for recurrence. We hypothesized that clinical results depend on tendon healing, which is obtained in almost all cases.Methods: The study included 46 small supraspinatus tears in 46 patients. Mean age was 56.8 years (range, 39-75 years). Preoperative and postoperative functions were assessed by the Constant-Murley (CM) score. The integrity of the repair was evaluated by ultrasonography. The average follow-up was 35 months (range, 24-60 months).Results: The mean absolute CM score improved significantly (P < .001) from 46.8 points (range, 34-62 points) preoperatively to 76 (range, 51-98) at the last follow-up. The result was excellent or good in 76.1%, and 42 (91.3%) were subjectively very satisfied or satisfied with the final result. The supraspinatus was completely healed on imaging studies in 33 patients (71.8%). The presence of an intratendinous cleavage of the supraspinatus was the only factor associated with a postoperative rerupture (P = .044). There was no association between functional and anatomic results.Conclusion: Arthroscopic repair of small supraspinatus tears yields favorable clinical and anatomic results at a mean of 35 months after surgery. Retearing is relatively common, but has no effect on the clinical result except that patients with radiographic signs of tendon healing appear to have increased postoperative ability to perform activities of daily living (P = .022). An intratendinous cleavage is the only significant predisposing factor for recurrence.

Rotator cuff tear arthropathy and deltoid avulsion treated with reverse total shoulder arthroplasty and latissimus dorsi transfer: case report and review of the literature

Danny P. Goel, Douglas C. Ross, Darren S. Drosdowech — 2011-12-23

Reverse total shoulder arthroplasty has demonstrated good to excellent functional results when used to treat cuff tear arthropathy. However, the success of this prosthesis is dependent upon an intact and functional deltoid muscle. Implantation of a reverse total shoulder arthroplasty (TSA) with a deficient deltoid provides no functional advantage over nonoperative care. Therefore, deltoid deficiency represents a strong contraindication to implantation of this prosthesis. Cuff tear arthropathy combined with deltoid muscle deficiency is a rare but extremely difficult reconstructive problem. This combined pathology significantly limits the surgical options available to patients and outcomes become less predictable. We report the first case of a patient treated with reverse TSA combined with latissimus dorsi transfer for an associated deltoid deficiency.

Delayed, transient musculocutaneous nerve palsy after the Latarjet procedure

Jodi D. Southam, Patrick E. Greis — 2011-12-23

Complications after the Bristow-Latarjet procedure are well described. Among these reported complications, neurologic compromise has been recounted in multiple studies. Most neurologic injuries after this procedure have been described as occurring immediately postoperatively and persisting. The purpose of this article is to report a patient with delayed musculocutaneous nerve palsy after the Latarjet procedure, which was transient in nature.

Chronic incarceration of the medial epicondyle: a case report

2012-01-04

Dislocation of the elbow is a frequent problem in children. There are usually associated lesions, such as an avulsion fracture of the medial epicondyle that can remain incarcerated within the joint. Such lesions have been described in the literature during the past century and are well known but may be missed in the emergency department because the bone fragment is usually small and may be hidden in routine x-ray views or may be confused with ossification centers.

Septic olecranon bursitis, contact dermatitis, and pneumonitis in a gas turbine engine mechanic

Nathaniel C. Wingert, Marlene DeMaio, Donald W. Shenenberger — 2012-01-24

In septic olecranon bursitis, a small, flattened, synovial membrane–lined sac overlying the olecranon process becomes symptomatically inflamed. Classic findings include localized tenderness, erythema, swelling, fever, chills, and a range of motion constrained by pain. The annual incidence of septic olecranon bursitis has been estimated at 10 cases per 10,000. The most common offending organism is Staphylococcus aureus.

Regarding: “Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis”: appropriate assessment of uncertainty

Hendrik Koffijberg — 2011-11-14

With interest I read the article on the expected-value decision analysis of operative vs nonoperative treatment after primary traumatic anterior glenohumeral dislocation by Bishop et al. Their article concludes that, in general, after a primary anterior glenohumeral dislocation, management with arthroscopic stabilization (AS) is preferable over nonoperative treatment (NOT). Although I do not question the validity of the analysis performed by the authors, I do believe it should have been extended with a full analysis of the uncertainty in model outcomes. Ultimately, uncertainty in model outcomes—here the utility values for the AS and NOT strategies—may lead to incorrect decision making, such as adopting a suboptimal strategy. It is this risk of making an incorrect decision that the authors failed to address.

Regarding: Humeral head abrasion: an association with failed superior labrum anterior posterior repairs

Thilo Patzer, Peter Habermeyer — 2011-11-21

We are writing this letter in reference to the recently published study by Byram et al, who evaluated a significant association of a humeral head abrasion underneath the long head of the biceps tendon (LHB) and failed superior labrum anterior posterior (SLAP) repairs. Interestingly, the authors found significantly associated humeral chondral lesions in failed SLAP repairs but not in untreated SLAP lesions, as we did. In our own series, we evaluated 182 SLAP lesions in 3395 consecutive shoulder arthroscopies. We thereby observed a significant association of humeral chondral lesions typically located underneath the LHB with nonoperatively treated SLAP lesions in about 20% compared with less than 5% without a SLAP lesion present. The association of SLAP lesions with glenohumeral chondral lesions was confirmed by a clinical and magnetic resonance imaging arthrography-controlled study by Lehmann et al, who evaluated glenohumeral chondral lesions after failed as well as after not-failed SLAP repairs. In addition to that, we have typically observed anteriorly located chondral lesions of the glenoid in untreated SLAP lesions as well.

Erratum to “Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions” [J Shoulder Elbow Surg 2012;21(1):13-22]

2012-01-30

In the above-mentioned article, the authors have noted that information derived from a study by Kibler et al has been misrepresented in the text. On page 20, the author's state: “In that study, the Modified Dynamic Labral Shear test yielded very poor diagnostic accuracy (LR+ = 0.38; LR- = 1.54),20 which was much worse than the findings of our study.”

2012-05-01

Sponsoring Societies

2012-05-01

Editorial Board

2012-05-01

Journal of Shoulder and Elbow Surgery

Editor's note

Radius morphology and its effects on rotation with contoured and noncontoured plating of the proximal radius

Radial head translation measurement in healthy individuals: the radiocapitellar ratio

Implantation of a porcine acellular dermal graft in a primate model of rotator cuff repair

A watertight construct in arthroscopic rotator cuff repair

Contrast-enhanced ultrasound characterization of the vascularity of the repaired rotator cuff tendon: short-term and intermediate-term follow-up

A pedicled bone graft from the acromion: an anatomical investigation regarding surgical feasibility

A three-dimensional analysis of humeral head retroversion

Retrograde nailing versus locking plate osteosynthesis of proximal humeral fractures: a biomechanical study

Voluntary activation deficits of the infraspinatus present as a consequence of pitching-induced fatigue

Effects of scapular dyskinesis and scapular assistance test on subacromial space during static arm elevation

Inferior tilt of the glenoid component does not decrease scapular notching in reverse shoulder arthroplasty: results of a prospective randomized study

The effect of capsular repair, bone block healing, and position on the results of the Bristow-Latarjet procedure (study III): long-term follow-up in 319 shoulders

Do insurance and race represent independent predictors of undergoing total shoulder arthroplasty? A secondary data analysis of 3529 patients

Polyethylene wear in retrieved reverse total shoulder components

Total shoulder replacement surgery with custom glenoid implants for severe bone deficiency

Pectoralis major tendon transfer for the treatment of scapular winging due to long thoracic nerve palsy

Outcomes of tendon fractional lengthenings to improve shoulder function in patients with spastic hemiparesis

Small supraspinatus tears repaired by arthroscopy: are clinical results influenced by the integrity of the cuff after two years? Functional and anatomic results of forty-six consecutive cases

Rotator cuff tear arthropathy and deltoid avulsion treated with reverse total shoulder arthroplasty and latissimus dorsi transfer: case report and review of the literature

Delayed, transient musculocutaneous nerve palsy after the Latarjet procedure

Chronic incarceration of the medial epicondyle: a case report

Septic olecranon bursitis, contact dermatitis, and pneumonitis in a gas turbine engine mechanic

Regarding: “Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis”: appropriate assessment of uncertainty

Regarding: Humeral head abrasion: an association with failed superior labrum anterior posterior repairs

Erratum to “Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions” [J Shoulder Elbow Surg 2012;21(1):13-22]

Contents

Sponsoring Societies

Editorial Board