Journal of Shoulder and Elbow Surgery

Note from the Editor-in-Chief

Bill Mallon — 2010-01-01

In his novel A Dry White Season, André Brink described the protagonist: “He continued the sluggish motion that carried them forward step-by-step. Looking ahead, we tended to lose courage. But looking back it was impossible to deny the length of the road already travelled.” And so it is with the world of shoulder and elbow surgery. These thoughts came to me recently when we were interviewing fellow candidates and I was describing my own circuitous route to the world of shoulder surgery.

A clinical comparison of two different double plating methods for intraarticular distal humerus fractures

Sang-Jin Shin, Hoon-Sang Sohn, Nam-Hoon Do — 2009-07-02

Background: This study compared clinical outcomes in patients with intraarticular distal humerus fractures treated using 2 different double plating methods.Method: Seventeen patients were treated by perpendicular plating (group I) and 18 by parallel plating (group II) methods. Arc of flexion averaged 106°±23° in group I and 112°±19° in group II.Results: Eleven patients in group I recovered full arc of flexion and 13 patients in group II achieved full arc of flexion. All patients obtained bone union, except 2 patients in group I. Nonunion in these patients developed in the supracondylar area. Complications developed in 6 patients in group I and in 8 in group II. No significant differences were found between the clinical outcomes of the 2o plating methods.Conclusion: Although more patients failed to achieve bony union in the perpendicular plating group, both parallel and orthogonal plates positioning can provide adequate stability and anatomic reconstruction of the distal humerus fractures.Level of Evidence: 2.

Measurement of the acromiohumeral interval on standardized anteroposterior radiographs: A prospective study of observer variability

2009-06-25

Background: An acromiohumeral interval narrower than 6 mm has been considered pathologic and strongly indicative for rotator cuff tears by numerous authors. This prospective study assessed interobserver and intraobserver variability in the radiographic measurement of the acromiohumeral interval.Material and methods: Five board-certified orthopedic surgeons independently reviewed 58 blinded, standardized anteroposterior shoulder radiographs. The acromiohumeral interval was measured in millimeters. The 5 investigators classified each image a second time in random order.Results: After the same 58 radiographs had been evaluated by the 5 investigators at both examination time points, no significant differences were noted in the interobserver and intraobserver measurements (P < .05). The respective maximum interobserver and intraobserver differences were 4 and 3 mm (range, 0-4 mm).Conclusion: The assessment of the acromiohumeral interval using standardized anteroposterior radiographs is a reliable and reproducible method of measurement.Level of evidence: Level 1; Investigating a diagnostic test.

Effectiveness of multidetector computed tomography arthrography for the diagnosis of shoulder pathology: Comparison with magnetic resonance imaging with arthroscopic correlation

Joo Han Oh, Jae Yoon Kim, Jung-Ah Choi, Woo Sung Kim — 2009-06-25

Hypothesis: This study evaluated the diagnostic efficacy of computed tomography arthrography (CTA) in the assessment of various shoulder pathologies with arthroscopic correlation. We hypothesized that CTA would be cost-effective and effectively comparable with magnetic resonance arthrography (MRA) for assessing labral detachments and full-thickness rotator cuff tears.Materials and methods: A musculoskeletal radiologist interpreted CTAs for 78 patients and MRAs for 70 patients. Each imaging study was evaluated for the presence of bony (Hill-Sachs) or labral (Bankart or superior labrum anteroposterior [SLAP]) lesions, and rotator cuff disorder (full- or partial-thickness tears). All patients subsequently underwent arthroscopic surgery. Detailed arthroscopic findings were reported and compared with CTA and MRA findings. The sensitivity, specificity, κ coefficients, and the area under the receiver operating characteristic (AUROC) curve were calculated.Results: The sensitivity, specificity, and agreement were comparable in each imaging study for Bankart, SLAP, and Hill-Sachs lesions, and full-thickness rotator cuff tears, but those of CTA were significantly lower than MRA for partial-thickness cuff tears. The AUROC curve for CTA and MRA were not significantly different for any of the pathologies, except partial-thickness cuff tears.Conclusions: Our data suggest that CTA is a cost-effective, useful method in the preoperative evaluation of labral abnormalities, such as Bankart and SLAP lesions. It may also be useful for the detection of full-thickness rotator cuff tears.Level of evidence: Level I; Diagnostic study.

Radial head fractures: Loss of cortical contact is associated with concomitant fracture or dislocation

Craig A. Rineer, Thierry G. Guitton, David Ring — 2009-09-07

Hypothesis: Among radial head fractures displaced greater than 2 mm (Broberg and Morrey modified Mason type 2), separation (complete loss of cortical contact) of at least 1 radial head fracture fragment is associated with a complex injury pattern, meaning that there are other concomitant elbow fractures or ligament injuries.Materials and methods: We identified 291 consecutive skeletally mature patients with 296 radial head fractures treated during a 6-year period. Of these, 121 consecutive fractures of part of the radial head displaced greater than 2 mm (type 2) were classified according to whether there was complete lack of cortical contact between a fracture fragment and the rest of the proximal radius. Predictors of isolated vs complex injury pattern were sought in bivariate and multivariable analyses.Results: Of 121 fractures, 30 (25%) were classified as having cortical contact, and 91 (75%) were classified as not having cortical contact. Ten (33%) with cortical contact were part of a complex elbow injury, and 83 of 91 fractures (91%) without cortical contact were part of a complex elbow injury (P < .01). Among the Mason type 2 fractures, loss of cortical contact was a significant predictor of a complex elbow injury in both bivariate and multivariable analyses, with an odds ratio of 21 (95% confidence interval, 7-59).Conclusions: Among Mason type 2 fractures, complete loss of cortical contact of at least one fracture fragment is strongly predictive of a complex injury pattern.Level of evidence: 4, Retrospective case series, Treatment study

The proximal ulna dorsal angulation: A radiographic study

Dominique M. Rouleau, Kenneth J. Faber, George S. Athwal — 2009-09-29

Background: Recognition of the proximal ulna dorsal angulation (PUDA) is important for anatomic reduction of proximal ulna fractures, nonunions, malunions, or osteotomies, especially when using newer straight precontoured ulnar plates. The purpose of this study was to characterize the PUDA in 50 patients with bilateral elbow radiographs.Materials and methods: Commercial software was used to magnify 100 bilateral elbow radiographs 4 times. The PUDA was measured from the intersection of lines perpendicular to the subcutaneous border of the olecranon and the ulnar shaft. The olecranon tip-to-apex distance of the PUDA was also measured. Three orthopedic surgeons independently examined the radiographs, and intraobserver and interobserver reliability was calculated using intraclass correlation.Results: A PUDA was present in 96% of radiographs. The average PUDA was 5.7° (range, 0°-14°). The Pearson correlation coefficient for a side-to-side comparison was 0.860 (P < .001). The average tip-to-apex distance was 47mm (range, 34-78mm). No correlation was identified with age. Intraobserver reliability was excellent for the PUDA and good for the tip-to-apex distance. Interobserver reliability was good for the PUDA and the tip-to-apex distance.Discussion: A mean PUDA of 5.7° is present in 96% of patients at an average of 47mm distal to the olecranon tip. Measurement of the PUDA has good-to-excellent interobserver and intraobserver reliability.Conclusion: Contralateral PUDA measurements are reliable in determining the angle in patients with comminution or distorted anatomy. Recognition of the PUDA may be helpful in anatomic plating of the ulna. Recognition of the PUDA may be helpful in anatomic plating of the ulna for fractures, nonunions or malunions.Level of evidence: Radiographic study.

Surgical treatment for osteochondritis dissecans of the humeral capitellum

2009-06-25

Background: Surgical treatments have been selected to treat advanced osteochondritis dissecans (OCD) of the humeral capitellum.Purpose: To evaluate the clinical results of surgical treatments for advanced capitellar OCD lesion and to clarify problems of poor clinical results.Methods: Cases were reviewed for 27 patients with advanced OCD lesions treated operatively. All patients were male baseball players, with a mean of 13.3 years at the time of surgery. Drilling only was performed for 3 patients, fragment fixation for 13 patients, and removal of the detached fragment with drilling for four patients. Since 2004, reconstruction of the articular surface with use of osteochondral autograft from the rib has been performed for 7 patients with osteochondral defect. Mean follow-up was 37.4 months. Follow-up assessment included modified elbow rating system, evaluation of radiographs, and return to sports.Results: Mean subjective score improved significantly from 70 to 96 postoperatively. Mean objective score improved significantly 71 to 81 postoperatively. A postoperative return to baseball was achieved by 25 patients. On the final radiographs, 4 patients showed flattening of >70% of the capitellum or degenerative changes, including insufficient remodeling of the lateral margin of the capitellum. Although patients could return to baseball, postoperative total arc of the elbow was decreased compared with the preoperative total arc.Conclusion: Surgical treatments were useful to restore advanced OCD lesions. Our results suggest that reconstruction of the lateral margin of the capitellum is important for achieving good clinical results.Level of evidence: Level 4.

Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws

2009-08-07

Background: The purpose of this study is to retrospectively evaluate the clinical outcomes of 18 patients with large coronal shear fractures of the capitellum and lateral trochlea that underwent open reduction and internal fixation with headless compression screws.Methods: Eighteen patients were identified (16 women, 2 men) with an average age of 45 years and an average follow-up of 26 months. Fractures were classified according to the Dubberley classification as 11 type-1A injuries and 7 type-2A injuries.Results: All patients, with the exception of 1, had good to excellent functional results by the Broberg-Morrey scale (mean score, 93.3). Average arc of motion was 128° in flexion/extension and 176° in pronation/supination. Radiographically, 3 patients had subsequent development of avascular necrosis and 5 developed arthrosis. No significant negative correlation was noted between the development of avascular necrosis and clinical outcome. Minor complications occurred in 2 patients, but there were no re-operations.Conclusion: Headless compression screw fixation allows for stable fixation in patients with large coronal shear fractures of the distal humerus without posterior comminution.Level of Evidence: 4

Transarticular shear fractures of the distal humerus

Neil Ashwood, Manish Verma, Mark Hamlet, Anand Garlapati, Quentin Fogg — 2009-11-02

Background: Capitellar fractures result from shearing and wedging forces transmitted to the elbow that create complex injury patterns that are difficult to stabilize. The fracture often extends into the trochlea and is associated with posterior comminution of the humerus and soft tissue injury. Diverse fixation techniques are required to restore the anatomy perfectly to ensure elbow function is regained.Materials and methods: This study presents the results of treatment of 26 patients followed up prospectively and treated within a week of injury. Clinical and radiographic evaluations were done annually by an independent reviewer, and the Mayo Elbow Performance Index (MEPI) was calculated.Results: Results were excellent in 9 patients, good in 9, and fair in 8 when assessed at an average of 46 months (range, 19-94 months) postoperatively using the MEPI, which averaged 81.3 (range 65-100). The poorer results occurred in patients with severe injuries associated with posterior comminution of the humerus and who required more extensive reconstructive procedures. All pain scores improved significantly and activities of daily living were restored in all groups, All returned to employment within 6 months, but 6 (3 type 2 and 3 type 3) had altered their roles from manual to administrative work.Conclusion: This series reflects the challenges in reconstructing precisely this cartilage-covered sphere, especially when there are multiple fragments. Modern techniques of fracture stabilization that concentrate on restoring a circular structure may require a different approach and engineering solutions.Level of evidence: Level 4; Case series, treatment study.

Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation

Paul Sethi, Elifho Obopilwe, Lina Rincon, Seth Miller, Augustus Mazzocca — 2009-07-02

Hypothesis: Tension slide repair maintains the strength of the standard cortical button repair but reduces gap formation at the repair. Distal biceps tendon repair with a suspensory cortical button has yielded the strongest published repair, despite observed gap formation and tendon pistoning. The tension slide technique (TST) was described to reduce gap formation while maintaining the strength of cortical button repair. This study evaluates the biomechanics of the TST compared with previously described EndoButton (Smith & Nephew, Memphis, TN) repair and the TST with and without an interference screw.Materials and methods: The study used 20 matched specimens: 5 had a standard cortical button repair, and 5 had biceps repair with the TST. An additional 10 specimens underwent a TST, 5 with an interference screw and 5 without. All were cyclically loaded for 3600 cycles. Gap formation and load to failure were measured.Results: The mean (SD) load to failure for standard technique was at 389 (148) N vs 432 (66) N for the TST (P = .28). The mean (SD) gap formation was 2.79 (1.43) mm with the standard repair and 1.26 (0.61) mm with the TST (P = .03). The mean (SD) load to failure with TST repair was 436 (103) N without the interference screw and 439 (94) N (P = 0.48) with the screw. The mean gap formation was 1.63 (1.09) mm without the screw and 1.45 (0.67) mm with the screw (P = .38.)Conclusion: This TST maintains the strength of the standard cortical button repair, but significantly reduces gap formation and motion at the repair site.Level of evidence: Basic science study.

Functional anatomy of the superior glenohumeral and coracohumeral ligaments and the subscapularis tendon in view of stabilization of the long head of the biceps tendon

2009-06-17

Background: Various findings in the lateral rotator interval to support the long head of the biceps tendon have been reported. The purpose of this study was to clarify the functional anatomy regarding the stabilization of the biceps tendon.Material and methods: Twenty embalmed shoulders were used for anatomic study, and 5 specimens of the anterosuperior part of the glenohumeral joint were histologically studied.Results: Anatomically, the most superior part of the subscapularis tendon was attached to the upper margin of the lesser tuberosity and extended as a thin tendinous slip to the fovea capitis of the humerus. The superior glenohumeral ligament ran spirally along the biceps tendon. Histologically, the superior glenohumeral ligament was attached to the tendinous slip. There was no clear boundary between the superior glenohumeral and coracohumeral ligament.Conclusion: To keep the biceps tendon in place and stabilized, tension in the superior glenohumeral ligament and the buttress support of the most superior insertion point of the subscapularis from behind the ligament may be necessary.Level of Evidence: Basic Science

Morphometry of the human bicipital groove (sulcus intertubercularis)

2009-07-02

Background: The bicipital groove is located between the greater and lesser tubercles at the proximal extremity of the humerus and extends inferiorly. Citations that anatomic variations of the groove could give rise to sliding of the biceps brachii muscle tendon led us to initiate a morphometric study on this groove.Materials and methods: The study was done on 50 dry humeral bones from adults of both genders and from both sides. A digital caliper rule was used to measure the length, thickness and width of the bicipital groove and the humerus. The angles of the bicipital groove were measured with a goniometer.Results: The average length of the groove was 8.1 cm and it corresponded to 25.2% of the length of the humerus. The width at the midpoint of the groove was 10.1 mm and corresponded to 49.7% to 54.5% of the width of the humerus. The depth was 4.0 mm and corresponded to 18.8% of the depth of the humerus. The mean angle formed by the groove lips was 106°.Conclusion: This study confirmed the variability of the measurements presented by the groove in relation to all the aspects considered.Level of Evidence: Basic Science.

The origin of the long head of the triceps: A cadaveric study

Matthew A. Handling, Alan S. Curtis, Suzanne L. Miller — 2009-09-14

Hypothesis: There is a paucity of literature examining the origin, size, and capsular contribution of the long head of the triceps brachii muscle. We hypothesize that there is a more extensive origin and capsular contribution than previously described.Materials and methods: Twenty fresh, frozen cadaveric specimens were dissected from a posterior and anterior approach exposing the long head of the triceps and the inferior capsule. The origin and size of the long head of the triceps and contribution to the capsule was documented.Results: The average age of the specimens was 65.8. At the scapula, the tendon width averaged 2.69cm at the insertion and the thickness averaged 0.47cm laterally and 0.29cm medially. The bony origin extended on the lateral border dorsal surface of the scapula in addition to the infraglenoid tubercle. The long head of the triceps gave a capsular contribution in each specimen. This contribution measured 1.43cm from superior to inferior and 1.01cm from anterior to posterior after dissecting the capsule off the glenoid.Discussion: We found the origin of the long head of the triceps had a more extensive bony attachment on the scapula then previously described. In addition, the long head of the triceps has a consistent contribution to the inferior shoulder capsule.Conclusion: The anatomic origin of the long head of the triceps gives a capsular contribution to the inferior glenohumeral capsule. The triceps may be affected by open and arthroscopic procedures that release or shift the posterior inferior glenohumeral capsule.Level of evidence: Cadaveric study.

Vascularity of the supraspinatus tendon three months after repair: Characterization using contrast-enhanced ultrasound

2009-06-15

Background: There has been limited in-vivo assessment of rotator cuff vascularity following repair. This study aims to characterize the vascularity of the shoulder 3 months following supraspinatus tendon repair.Methods: Twenty-nine patients (average age, 61.4 years) underwent Perflutren lipid microsphere contrast-enhanced shoulder ultrasound examinations 3 months after arthroscopic rotator cuff repair. Each shoulder was scanned at rest and following exercise using linear phased array 9-MHz transducer optimized to detect the contrast agent. Blood flow was quantified off-line using ultrasound imaging quantification and analysis software (QLAB, Philips, Andover, MA). Peak enhancement (vascular volume) and rate of rise (perfusion) were determined for 3 regions of interest: peribursal area, supraspinatus tendon, and anchor site.Results: Peak enhancement and rate of rise were greatest in the peribursal soft tissue and anchor site. Resting peak enhancement and rate of rise were significantly lower within the tendon compared to the other 2 regions (P < .001). Exercise resulted in increased enhancement and rate-of-rise to all 3 regions, but had a significant predilection towards increasing vascular volume within the peri-bursal region (P = .026).Conclusion: At 3 months following repair, the majority of blood flow to the repair is derived from the peribursal soft tissues and the anchor site. The tendon, particularly those with a defect at 3 months, is relatively avascular. Though limited by inclusion of only a single time point, this study introduces a new technique to quantify vascularity following supraspinatus repairs and suggests that the surrounding vascular milieu may play a role in tendon healing.Level of Evidence: Basic Science.

Suture anchor loading after rotator cuff repair: Effects of an additional lateral row

Kevin J. Kulwicki, Young W. Kwon, Frederick J. Kummer — 2009-06-29

Hypothesis: Our initial hypothesis was that the medial row of double-row rotator cuff repair techniques would bear most of the load on the repaired cuff.Materials and methods: Six cadaver shoulders underwent simulated rotator cuff repairs using sequential single row, double-row, and suture-bridge repair techniques. Suture tensions at each anchor were measured for several static, simulated shoulder positions by specially designed, instrumented anchors.Results: Significantly greater suture tensions were measured in the anchors in a single row repair construct than either the double row repair or suture bridge repair construct (P < .001). In the double-row and suture bridge techniques, there was no apparent difference in the loads born by the medial and lateral row anchors. Shoulder abduction from 45° to 60° had little effect on anchor tensions; 45° internal and external rotation significantly (P = .032) increased loads on the anterior and posterior anchors by at least 125%.Discussion: Forces are transmitted through the entire portion of the tendon at its humeral fixation, loading the lateral anchors as well as the medial row for the techniques studied. This “load sharing” can explain the higher fixation strengths of double row techniques seen experimentally.Conclusion: The magnitude and distribution of anchor suture tensions could have important implications for lateral row fixation devices and post-operative positioning and activity.Level of Evidence: Basic Science.

Computer simulation of humeral shaft fracture in throwing

2009-07-02

Hypothesis: Throwing fractures of the humerus are well known, but the exact mechanism of injury is not clear. It has been postulated that these may be stress fractures because the forces have not seemed sufficient to cause acute fractures while throwing.Materials and methods: Using finite element analysis, we reproduced fractures of the humerus using 3-dimensional models built from computed tomography images of 5 healthy volunteers. To apply the load during throwing, we assumed that the humeral head was completely fixed, and external rotation torque was applied to the distal end of the humerus until the stress of the bone elements became greater than yield stress. We reproduced the fracture line by removing the bone elements.Results: The maximum stress concentration was seen in the distal shaft, where a typical spiral fracture was created in all cases. In the humeral models, the torque required to initiate fracture ranged from 51 to 70 Nm. A strong correlation existed between the torque required to initiate fracture and thickness of the humeral cortical bone (R2 = 0.74).Conclusion: These results indicate that thickness of the humerus represents one factor contributing to fractures that occur while throwing.Level of evidence: Basic science study

Predicting transfusion in shoulder arthroplasty

2009-08-07

Background: This study was conducted to evaluate the incidence of transfusion in shoulder arthroplasty, determine clinical factors associated with increased risk for transfusion, and develop an algorithm to assist the surgeon in preoperative planning with regards to blood management.Material and methods: The study had 2 phases: (1) development of a clinical prediction rule for transfusion using 280 procedures and (2) a validation study of the algorithm applied to 109 new patients. Phase 1 consisted of a retrospective record review of 280 consecutive shoulder arthroplasties to determine risk factors for transfusion. Phase 1 also identified a preoperative hemoglobin level of less than 12.5 g/dL as predictive of the need for blood transfusion. This cutoff was prospectively applied to 109 patients undergoing shoulder arthroplasty in phase 2.Results: The transfusion rate for phase 1 was 19.6%. Preoperative hemoglobin level (P < .001), age (P= .003), and the number of comorbid conditions (P = .005) were statistically significant risk factors. Patients with a preoperative hemoglobin level of less than 12.5 g/dL have a 4-fold increased risk of requiring a blood transfusion. In phase 2, the cutoff of less than 12.5 g/dL yielded a sensitivity of 88%, specificity of 78%, and positive and negative likelihood ratios of 4.0 and 0.15, respectively.Conclusion: Preoperative hemoglobin level, age, and number of comorbid conditions are all predictive of transfusion in shoulder arthroplasty. Tailoring blood ordering based on a preoperative hemoglobin level of 12.5 g/dL is safe and effective.Level of evidence: Prognostic study, level 2.

Infectious and thromboembolic complications of arthroscopic shoulder surgery

2009-06-26

Hypothesis: This study investigates the rate of infectious and thromboembolic complications in shoulder arthroscopy and their association with pharmacologic prophylaxis.Materials and methods: On behalf of the Italian Society for Knee Surgery, Arthroscopy, Sport Traumatology, Cartilage and Orthopaedic Technologies (SIGASCOT), we asked the members to complete an on-line Web survey about their experiences and strategies of prophylaxis in shoulder arthroscopy.Results: In the period 2005-2006, 9385 surgeries were performed. We report 15 infections and 6 DVTs. The overall rate of infections was 0.0016 (1.6/1000) and the rate of DVTs was 0.0006 (0.6/1000)Conclusion: The association between infection and antibiotic prophylaxis was significant (P=0.01); however, the risk of DVTs was not decreased with heparin prophylaxis.Level of evidence: Level 3.

Arthroscopic treatment of internal rotation contracture and glenohumeral dysplasia in children with brachial plexus birth palsy

2009-08-07

Background: The purpose of the study was to assess the ability of arthroscopic anterior release, +/- tendon transfers to maintain shoulder joint alignment in children with brachial plexus palsy, and to assess their outcome after arthroscopic reduction.Methods: Forty-four patients underwent arthroscopic release, +/- tendon transfers to realign a dysplastic glenohumeral joint in children with brachial plexus palsy. Twenty-eight children underwent isolated release and 16 children underwent concomitant tendon transfers. MRI and clinical measurements were used to assess outcome at 1-year follow-up.Results: There was a significant improvement (P < .001) in both retroversion from −34 (±15) to -19 (±13), and percentage of the humeral head anterior to the middle of the glenoid fossa (PHHA) from 19% (±12%) to 33% (±12%), at 1 year. Passive external rotation increased from −26 (±20) degrees to 47 (±17) degrees (P < .001). Active elevation increased from 112 (±28) degrees to 130 (±38) (P = .008) degrees. Patients that underwent tendon transfers obtained greater active elevation, 147 (±9) degrees compared to 119 (±6) degrees. Mallet aggregate and domain scores also demonstrated statistically significant improvements.Conclusions: Our results after arthroscopic release +/- tendon transfers are encouraging with improvements in joint alignment and clinical evaluations following surgery. The clinical improvements paralleled the MRI corrections. Importantly, superior outcomes were associated with better preoperative clinical and MRI status. This indicates that early recognition of glenohumeral dysplasia and timely intervention results in better shoulder motion and improved joint alignment.Level of Evidence: 4.

Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression

Hanna Björnsson, Rolf Norlin, Anders Knutsson, Lars Adolfsson — 2009-06-25

Background: A successful clinical result is reported in 75% to 85% of impingement patients after arthroscopic subacromial decompression. The result is maintained over time, but few studies have investigated the integrity of the rotator cuff in these patients.Materials and methods: Using ultrasonography, we examined the integrity of the rotator cuff in 70 patients 15 years after arthroscopic subacromial decompression. All patients had an intact rotator cuff at the index procedure.Results: Tendons were still intact in 57 patients (82%), 10 (14%) had partial-thickness tears, and 3 (4%) had full-thickness tears.Discussion: The total number of 18% tears (partial and full thickness) in this study, including patients clinically diagnosed with subacromial impingement at a mean age of 60 years, is unexpectedly low compared with 40% degenerative tears reported in asymptomatic adults of the same age.Conclusion: Arthroscopic subacromial decompression seems to reduce the prevalence of rotator cuff tears in impingement patients. This appears attributable to elimination of extrinsic factors such as mechanical wear and bursitis. The potential effect of surgery on intrinsic cuff degeneration is unknown, but intrinsic factors may explain tears still developing despite decompression.Level of evidence: Level III, therapeutic study.

Prevalence and risk factors of a rotator cuff tear in the general population

2009-06-22

Background: Little information is available about the epidemiology of rotator cuff tears in a population-based study. The purpose of this study was to elucidate the true prevalence of rotator cuff tears regardless of the presence or absence of symptoms in the general population and to assess the relationship between tears and their backgrounds.Material and methods: A medical check-up was conducted for residents of a mountain village in Japan. The subjects consisted of 683 people (total of 1,366 shoulders), including 229 males and 454 females with a mean age of 57.9 years (range, 22-87). We examined their background factors, physical examinations and ultrasonographic examinations on both shoulders.Results: Rotator cuff tears were present in 20.7% and the prevalence increased with age. Thirty-six percent of the subjects with current symptoms had rotator cuff tears, while 16.9% of the subjects without symptoms also had rotator cuff tears. Rotator cuff tears in the general population were most commonly associated with elderly patients, males, affected the dominant arm, engaged in heavy labor, having a history of trauma, positive for impingement sign, showed lesser active forward elevation and weaker muscle strength in abduction and external rotation. A logistic regression analysis revealed the risk factors for a rotator cuff tear to be a history of trauma, dominant arm and age.Conclusion: 20.7% of 1,366 shoulders had full-thickness rotator cuff tears in the general population. The risk factors for rotator cuff tear included a history of trauma, dominant arm and age.Level of evidence: Level 3.

The cortical ring sign: A reliable radiographic landmark for percutaneous coracoclavicular fixation

2009-07-21

Background: For treatment of acute acromioclavicular separations, we have been using a reproducible radiographic view of the coracoid—the cortical ring sign—that we believe allows for placement of percutaneous coracoclavicular fixation safely and reliably in the center of the coracoid base, while avoiding the coracoid tip. This study evaluates the coracoid anatomy that the cortical ring sign represents, its utility for guiding fixation trajectory, and the proximity of neurovascular structures to this proposed trajectory.Materials and methods: Kirschner wires were used to measure the orientation of the fluoroscopic beam in relation to the scapula and the proposed fixation trajectory using this radiographic view.Results: The cortical ring sign is achieved by first directing the x-ray beam perpendicular to the medial border of the scapula in the parasagittal plane and 49° off the axis of the scapular spine in the axial plane, then fine-tuning until the coracoid cortical ring becomes evident. The nearest neurovascular structures to the fixation trajectory are the suprascapular artery and nerve (< 2 cm).Conclusion: The cortical ring sign view targets the coracoid base and, as such, allows reliable, safe, percutaneous fixation in the center of the coracoid base.Level of Evidence: Basic Science.

Attachments of muscles as landmarks for implantation of shoulder hemiarthoplasty in fractures

2009-06-15

Background: The attachments of muscles and the position of the humeral head are important for a good functional outcome of shoulder hemiarthroplasties after displaced fractures of the proximal humerus. Deviations in the attachments and changes in their spatial position with respect to the humeral head during surgical reconstruction change the biomechanics and reduce the range of motion of the should joint postoperatively.Methods and Results: We used 198 humerus preparations and using 3-dimensional analysis measured the angular relationships between the humeral head axis and medial margin of the greater tuberosity (11.9° ± 9.1°), lateral margin of the lesser tuberosity (48.0° ± 7.8°), and the crest of the greater tuberosity (27.1° ± 9.6°).Conclusion: This study provides average values of the positions of the greater and lesser tuberosities with respect to the humeral head axis. We show that the greater and lesser tuberosities are more reliable than the transepicondylar line for reconstruction of humeral head retroversion.Level of Evidence: Basic Science.

Early clinical results following staged bilateral primary total shoulder arthroplasty

2009-06-15

Background: The advantages of performing either a single- or 2-staged joint replacement has been reviewed extensively in the hip and knee arthroplasty literature, but far less data exist regarding total shoulder replacements. In the appropriate clinical setting, bilateral total shoulder arthroplasty yields excellent functional results with a low complication profile.Materials and methods: We evaluated retrospectively the records of 13 consecutive patients (26 shoulders) who underwent staged bilateral primary total shoulder replacements by a single surgeon, with a minimum follow-up of 12 months for each side (range, 12.0-61.5). The interval between replacements averaged 7.4 months (range, 0.5-26.0).Results: The mean unadjusted baseline Constant score for the first versus the second side was not significant (35 vs 41, P = .3). These scores improved to 73 and 72 by final follow-up (both P < .0001). Mean pain scores on the visual analog scale (VAS) improved from 6.9 to 0.9 (P < .0001). We found no difference in the estimated blood loss (EBL), operative time, or hospital length of stay (LOS) between the sides. Significantly higher mean scores were demonstrated in all components of the SF-36 questionnaire over a normalized cohort of U.S. age-matched males and females by final follow-up. All patients were satisfied with both procedures.Conclusion: Staged, bilateral total shoulder arthroplasty results in excellent functional outcomes and high satisfaction in subjective patient assessment. We currently recommend a minimum of 6 weeks between replacements to allow for appropriate tissue healing and rehabilitation.Level of Evidence: 4.

Survivorship of the humeral component in shoulder arthroplasty

2009-06-25

Background: Loosening of the humeral component is rarely a cause for revision. This study was conducted to determine long-term survivorship of humeral components and investigate the risk factors associated with humeral component removal or revision.Materials and methods: From 1984 to 2004, 1423 patients underwent 1584 primary Neer and Cofield shoulder arthroplasties. The Kaplan-Meier method was used to estimate implant survival. Cox proportional hazards regression was used to assess the effects of age, gender, etiology of the disease, surgery type (hemi vs total), fixation (cemented vs noncemented), and the humeral component design (Neer II, Cofield 1 or 2) with survival free of revision or removal of the humeral component.Results: There were 108 revisions and 17 removals of the humeral component. Estimates of survivorship free of revision or removal of the humeral component for any reason was 94.8% (95% confidence interval [CI], 93.6-96.0) at 5 years, 92.0% (95% CI, 90.4-93.6) at 10 years, 86.7% (95% CI, 84.2-89.4) at 15 years, and 82.8% (95% CI, 78.5-87.5) at 20 years. Younger age, male gender, replacement due to posttraumatic arthritis, an uncemented component, and use of a metal-backed glenoid component increased the likelihood of humeral component failure.Conclusions: The need for revision of the humeral component is commonly related to glenoid or glenoid component issues. Patient and diagnostic factors play a role in implant survival; implant type and method of fixation are less important.Level of evidence: Level 4; Case series, treatment study.

Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: A diagnostic sign for an osseous defect of the anterior glenoid rim

2009-06-25

Background: The integrity of the glenoid defines the surgical treatment in anterior shoulder instabilities. The reliability of plain radiographs to detect anterior glenoid rim deficiencies was determined.Materials and methods: The anterior sclerotic glenoid line (SGL) was assessed on anteroposterior radiographs of 86 shoulders (34 anterior instabilities, 15 posterior instabilities, 37 stable) and compared with computed tomography (CT) scans (gold standard). A loss of the SGL (LSGL) was defined as a positive LSGL sign.Results: On CT scans, 25 of 34 shoulders (74%) with anterior instabilities showed a defect of the anterior glenoid rim. No defects were found in shoulders without anterior instabilities. LSGL correctly predicted an anterior glenoid rim lesion in 16 (examiner A) or 14 (examiner B) of the 25 anterior instabilities (sensitivity, 64% and 56%), without a false-positive diagnosis (specificity, 100%).Conclusion: The LSGL on anteroposterior radiographs is a moderately sensitive but highly specific finding for anterior glenoid rim defects.Level of evidence: Level 4; Diagnostic study, case control study.

A systematic review of the psychometric properties of the Constant-Murley score

Jean-Sébastien Roy, Joy C. MacDermid, Linda J. Woodhouse — 2009-06-26

Hypothesis: The purpose of this study was to conduct a systematic review of the psychometric evidence relating to Constant-Murley score.Materials and methods: A search of 3 databases (Medline, CINAHL, and EMBASE) and a manual search yielded 35 relevant publications. Pairs of raters used structured tools to analyze these articles, through critical appraisal and data extraction. A descriptive synthesis of the psychometric evidence was then performed.Results: Quality ratings of 23% of the studies reviewed reached a level of 75% or higher. Studies evaluating the content validity of the Constant-Murley score suggest that the description in the original publication is insufficient to accomplish standardization between centers and evaluators. Despite this limitation, the Constant-Murley score correlates strongly (≥ 0.70) with shoulder-specific questionnaires, reaches acceptable benchmarks (ρ > 0.80) for its reliability coefficients, and is responsive (effect sizes and standardized response mean > 0.80) for detecting improvement after intervention in a variety of shoulder pathologies.Discussion: This systematic review provides evidence to support the use of the Constant-Murley score for specific clinical and research applications but underscores the need for greater standardization and precaution when interpreting scores. Methods to improve standardization and measurement precision are needed. Responsiveness has been shown to be excellent, but some properties still need be evaluated, particularly those related to the absolute errors of measurement and minimal clinically important difference.Conclusion: Given the widespread acceptance for usage of the Constant-Murley score in clinical studies and early indications that the measure is responsive, studies defining more rigid standardization of the tools/procedures are needed.Level of evidence: Level 1

Heterotopic ossification—A complication of elbow arthroscopy: A case report

Scott C. Hughes, Kevin A. Hildebrand — 2009-08-03

The occurrence of heterotopic ossification (HO) is a well described manifestation following trauma, surgical intervention, neurological insults, in diffuse idiopathic skeletal hyperostosis (DISH) and genetic conditions with abnormalities in bone morphogenetic protein (BMP) metabolism. HO is the formation of bone in anatomic locations foreign to regular bone growth. HO usually presents itself clinically as joint pain and decreased range of motion. Occasionally joint erythema and effusions are noted. There is substantial evidence to suggest that HO is a common complication following total hip arthroplasty. Reigler (1976) concluded that 2-7% of patients suffer extensive HO following total hip arthroplasty. Further, a more recent study using a similar patient population has suggested that up to 56% of patients have some radiographic evidence of HO post-operatively.

Fibrous dysplasia around the elbow

Zinon T. Kokkalis, Sameer Jain, Dean G. Sotereanos — 2009-09-10

First named by Lichtenstein in 1938, fibrous dysplasia is a noninherited, skeletal developmental abnormality that commonly presents in adolescents and young adults. Normal marrow and cancellous bone are replaced and weakened by immature woven bone and a dense fibrotic stroma containing a disorganized matrix of bony trabecular spicules. Fibrous dysplasia accounts approximately for 5% to 7% of benign bone tumors. It may be monostotic, accounting for 70% to 80% of cases, or polyostotic. Fibrous dysplasia frequently occurs in the ribs, femur, tibia, skull, pelvis, spine and shoulder. Within the long bones, the lesions are predominately diaphyseal, with an epiphyseal lesion rarely occurring.

Hemilateral resurfacing arthroplasty in posttraumatic degenerative elbow resulting from humeral capitellum malunion

2009-10-05

Secondary osteoarthritis, malunion, or nonunion associated with stiffness are common conditions in elbows after trauma. These conditions may be treated by various surgical methods when the elbow joint is severely compromised. In young, active patients with extensive joint destruction, interposition or distraction arthroplasty may be considered, whereas in the presence of malunited or ununited intra-articular fractures, open reduction and internal fixation can restore joint congruity. In the elderly with limited functional demand, these conditions may be treated by total elbow arthroplasty. When the lesion is only or essentially represented by malunion or nonunion of the capitellum, reconstruction can be performed as an alternative to excision of the bone fragment.

Iatrogenic thoracic outlet syndrome caused by revision surgery for multiple subacute fixation failures of a clavicle fracture: A case report

John G. Skedros, Bryce B. Hill, Todd C. Pitts — 2009-09-07

During revision surgical fixation of clavicle fractures and fracture nonunions, compression of the prominent neurovascular structures of the thoracic outlet can be an important potential complication. In this report, we describe the case of a manual laborer who had iatrogenic compression of the thoracic outlet of his dominant arm by fracture callus during revision surgery after multiple subacute fixation failures. The surgeon initially failed to recognize that the anatomic alignment of the clavicle fracture during osteosynthesis had resulted in thoracic outlet syndrome (TOS), as definitively established by venogram 14 days postoperatively. This case illustrates how the constellation of signs and symptoms can be misleading when this problem occurs in a subacute setting.

Anchor fracture leading to supraspinatus failure

John C. Dunn, Darren J. Friedman, Laurence D. Higgins — 2009-09-22

Rotator cuff tears are extremely common and often times are both painful and debilitating. In the last 2 decades, anchor technology has vastly improved, and now anchor failure represents an uncommon mode of rotator cuff repair failure. While re-tears are most often caused by tendon pulling through suture, anchor pullout or failure, particularly in osteoporotic bone, is of great concern. New anchor designs have mitigated this to some extent and bioabsorbable anchors are becoming increasingly more popular. We present a case describing a novel failure method of a bioabsorbable anchor that resulted in a failed rotator cuff repair.

Sponsoring Societies

2010-01-01

Editorial Board

2010-01-01

Journal of Shoulder and Elbow Surgery

Note from the Editor-in-Chief

A clinical comparison of two different double plating methods for intraarticular distal humerus fractures

Measurement of the acromiohumeral interval on standardized anteroposterior radiographs: A prospective study of observer variability

Effectiveness of multidetector computed tomography arthrography for the diagnosis of shoulder pathology: Comparison with magnetic resonance imaging with arthroscopic correlation

Radial head fractures: Loss of cortical contact is associated with concomitant fracture or dislocation

The proximal ulna dorsal angulation: A radiographic study

Surgical treatment for osteochondritis dissecans of the humeral capitellum

Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws

Transarticular shear fractures of the distal humerus

Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation

Functional anatomy of the superior glenohumeral and coracohumeral ligaments and the subscapularis tendon in view of stabilization of the long head of the biceps tendon

Morphometry of the human bicipital groove (sulcus intertubercularis)

The origin of the long head of the triceps: A cadaveric study

Vascularity of the supraspinatus tendon three months after repair: Characterization using contrast-enhanced ultrasound

Suture anchor loading after rotator cuff repair: Effects of an additional lateral row

Computer simulation of humeral shaft fracture in throwing

Predicting transfusion in shoulder arthroplasty

Infectious and thromboembolic complications of arthroscopic shoulder surgery

Arthroscopic treatment of internal rotation contracture and glenohumeral dysplasia in children with brachial plexus birth palsy

Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression

Prevalence and risk factors of a rotator cuff tear in the general population

The cortical ring sign: A reliable radiographic landmark for percutaneous coracoclavicular fixation

Attachments of muscles as landmarks for implantation of shoulder hemiarthoplasty in fractures

Early clinical results following staged bilateral primary total shoulder arthroplasty

Survivorship of the humeral component in shoulder arthroplasty

Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: A diagnostic sign for an osseous defect of the anterior glenoid rim

A systematic review of the psychometric properties of the Constant-Murley score

Heterotopic ossification—A complication of elbow arthroscopy: A case report

Fibrous dysplasia around the elbow

Hemilateral resurfacing arthroplasty in posttraumatic degenerative elbow resulting from humeral capitellum malunion

Iatrogenic thoracic outlet syndrome caused by revision surgery for multiple subacute fixation failures of a clavicle fracture: A case report

Anchor fracture leading to supraspinatus failure

Sponsoring Societies

Contents

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Contents