Journal of Shoulder and Elbow Surgery - Articles in Press

Postoperative rupture of the anterolateral deltoid muscle following reverse total shoulder arthroplasty in patients who have undergone open rotator cuff repair - Corrected Proof

Adam N. Whatley, Rachel L. Fowler, Jon J.P. Warner, Laurence D. Higgins — 2010-08-30

Background: Postoperative ruptures of the antero-lateral deltoid in patients with reverse total shoulder arthroplasty utilizing the delto-pectoral approach following failed mini-open or open rotator cuff repairs have not been reported in the English literature. The incidence of this complication is unknown.Materials and methods: A retrospective review of 199 patients who underwent reverse total shoulder arthroplasty utilizing a deltopectoral approach was performed. These procedures were performed by 2 surgeons in 2 hospitals. There were 3 patients who had postoperative rupture of the deltoid. These ruptures occurred without any history of trauma to the patient. In all 3 patients, past surgical history was significant for a rotator cuff repair utilizing a mini-open or mini-open modified to open approach. Successful repair of the deltoid was achieved using a transosseous suture repair in all 3 patients.Results: At most current follow-up (all >12 months), average forward elevation was 120°. A small residual anterior deltoid defect was present in all 3 patients, but pain was quantified as 0-4 out of 10 and radiographs demonstrated satisfactory position of the reverse arthroplasty implants.Conclusion: Postoperative ruptures of the antero-lateral deltoid can occur in patients who have undergone reverse total shoulder arthroplasty, utilizing the delto-pectoral approach following failed mini-open or open rotator cuff repairs. A supero-lateral approach during reverse total shoulder arthroplasty could be useful in assessing and possibly reinforcing a deltoid origin previously damaged or repaired during mini-open or open rotator cuff repair.

Fixation of the glenoid component in total shoulder arthroplasty: What is “modern cementing technique?” - Corrected Proof

Allan A. Young, Gilles Walch — 2010-08-30

▪▪▪

Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis - Corrected Proof

Robert Bartelt, John W. Sperling, Cathy D. Schleck, Robert H. Cofield — 2010-08-27

Background: The younger patient with glenohumeral arthritis presents a challenge because of concerns about activity and frequency of failure. The purpose of this study was to define the results, complications, and frequency of revision surgery in this group.Materials and methods: Between 1986 and 2005, 46 total shoulder arthroplasties and 20 hemiarthroplasties were performed in 63 patients who were aged 55 years or younger and had chronic shoulder pain due to glenohumeral osteoarthritis. All 63 patients had complete preoperative evaluation, operative records, and minimum 2-year follow-up (mean, 7.0 years) or follow-up until revision.Results: Nine shoulders underwent a revision operation. The implant survival rate was 92% (95% confidence interval, 77%-100%) at 10 years for total shoulder arthroplasty and 72% (95% confidence interval, 54%-97%) for hemiarthroplasty (Kaplan-Meier result). Patients who underwent total shoulder arthroplasty had less pain (P = .01), greater active elevation (P = .05), and higher satisfaction (P = .05) at final follow-up compared with those who underwent hemiarthroplasty. Complete radiographs were available for 47 arthroplasties with a minimum 2-year follow-up or follow-up until revision (mean, 6.6 years). More than minor glenoid periprosthetic lucency or a shift in component position was present in 10 of 34 total shoulder arthroplasties. Moderate to severe glenoid erosion was present in 6 of 13 hemiarthroplasties.Conclusions: This study indicates that there is intermediate- to long-term pain relief and improvement in motion with shoulder arthroplasty in young patients with osteoarthritis. These results favor total shoulder arthroplasty in terms of pain relief, motion, and implant survival.

Surgical treatment of clavicular malignancies - Corrected Proof

Jing Li, Zhen Wang, Jun Fu, Lei Shi, Guoxian Pei, Zheng Guo — 2010-08-27

Hypothesis: Primary and metastatic malignancies of the clavicle are very rare, and little literature is available regarding the long-term functional and oncologic outcome after surgical treatment. To what advantage or disadvantages clavicle reconstruction following claviculectomy will lead is not clear. The hypothesis is that there is no advantage of allograft reconstruction over no reconstruction in terms of the functional outcome and complications.Materials and methods: From 1999 to 2009, 11 patients with clavicular malignancy underwent total or subtotal claviculectomy with or without allograft reconstruction. Oncologic and functional results were assessed.Results: The average age at time of operation was 31.9 years. The mean follow-up time was 42.4 months. Six patients had allograft reconstruction after tumor resection, and 5 had claviculectomy alone. No local recurrence occurred. The oncologic result was continuous disease-free in 5 patients, no evidence of disease in 1, alive with disease in 2, and died of disease in 3. Patients with and without allograft reconstruction had average Musculoskeletal Tumor Society score of 92.2% vs 96.2% and Constant-Murley scores of 84.8 vs 88.8. Patients with allograft reconstruction had more complications than patients without reconstruction.Discussion: Considering complications, allograft reconstruction does not guarantee a satisfied patient. Total or subtotal excisions of the clavicle without reconstruction for malignancies are rarely associated with a clinically significant loss of function. Furthermore, the average time of full use of upper limb was slower in patients with reconstruction compared with those without reconstruction.Conclusions: Clavicular malignancies had poor prognosis, although claviculectomy could provide good local tumor control. Allograft reconstruction after claviculectomy was not justified for malignancies in terms of its functional outcomes as well as complications.

Surgical anatomy of the axillary nerve and its implication in the transdeltoid approaches to the shoulder - Corrected Proof

2010-08-27

Background: Traumatic and iatrogenic injuries of the axillary nerve (AN) are frequent in clinical practice; nevertheless, its anatomy and its relationships with the transdeltoid approaches to the shoulder are not well documented.Materials and methods: Anatomic study was performed on 16 shoulders of unembalmed cadavers. A proximal humeral internal locking system (PHILOS) plate was placed to simulate the osteosynthesis of a fracture of humeral surgical neck. The relationships between the plate and the nerve were evaluated. Selective dissection of all the nerve branches inside the deltoid muscle was performed.Results: The mean distance between the point where the AN entered into the deltoid muscle and the humeral head was 5.0 cm, and it was 6.8 cm from the acromion. The mean distance between the origins of the anterior and posterior branches of the axillary nerve was 5.4 cm. The mean diameter of the AN was 0.57 cm, the anterior branch diameter was 0.40 cm, of posterior branch diameter was 0.33 cm, and the teres minor branch diameter was 0.24 cm. The application of the PHILOS plate demonstrated that in 100% of cases, the 2 distal holes of the plate of those dedicated to the humeral head coincided with the passage of AN.Discussion: The different patterns of nerve branches inside the deltoid muscle show that the “safe zone” during transdeltoid approaches is the anterior region of the deltoid muscle for a maximum of 6.7 cm from the acromion. In addition, the insertion of the 2 distal screws of those dedicated to humeral head of the plate should be avoided.

A prospective analysis of interscalene brachial plexus blocks performed under general anesthesia - Corrected Proof

Gary Misamore, Brian Webb, Sherman McMurray, Peter Sallay — 2010-08-16

Background: The purpose of this prospective study was to assess the safety and efficacy of interscalene brachial plexus block anesthesia when performed on patients who were anesthetized with a general anesthetic prior to the performance of the block.Methods: Patients were assessed postoperatively through surveys, interviews, and physical examinations to document block success, duration of anesthesia, block side effects, and persistent neurological complications. Nine-hundred fifty-one patients were available for the analysis.Results: The overall block success rate was 97% and the mean duration of anesthesia provided by the blocks was 23.9 hours. Immediate postoperative block side effects occurred in 16% (142 of 910), persistent neurological complications occurred in 4.4% (40 of 910) of patients, and long-term neurologic complications occurred in 0.8% (8 of 910).Conclusion: Our study results suggest that the rates of success and complications associated with the performance of interscalene block regional anesthesia performed after induction of general anesthesia are similar to the results demonstrated in prior studies in which brachial plexus block was performed on nonanesthetized patients. Although significant complications were not common, this procedure is not without risk and can result in long-term neurologic complications.

Metaversion can reliably predict humeral head version: A computed tomography-based validation study - Corrected Proof

George S. Athwal, Joy C. MacDermid, Danny P. Goel — 2010-08-13

Hypothesis: Circumstances occur when the determination of anatomic humeral head version is difficult. In the setting of irreparable proximal humeral fracture, there are few reliable intraoperative landmarks to determine anatomic humeral head version. This study tested our hypothesis that the metaphyseal version (metaversion) is a landmark that can assist with correct head version and used computed tomography (CT) to evaluate its reliability as a predictor of anatomic version.Materials and methods: CT scans from 50 consecutive patients (20 women, 30 men) were examined using commercial software. Patients were a mean age of 46 years (range, 17-85 years). Exclusion criteria included previous fracture, arthritis, or humeral deformity. The metaversion and humeral head version were measured. Measurements were conducted independently by 2 surgeons blinded to the results of the other. Interobserver and intraobserver reliability was calculated using intraclass correlation.Results: The mean difference between the metaversion and the humeral head version was 2.5° (95% confidence interval [CI], 0.9°-3.9°). The mean difference between metaversion and humeral head version was 1.8° (95% CI, 0.0°-3.6°) in women, 2.9° (95% CI, 0.6°-5.1°) in men, 2.4° (95% CI: 0.6°-4.1°) in right shoulders, and 2.5° (95% CI, –0.1° to 5.1°) in left shoulders. Interrater and intrarater reliability was excellent, 0.97 and 0.98, respectively.Conclusions: Proximal humeral metaphyseal version (metaversion) is an accurate predictor of ipsilateral humeral head version.

Open reduction and internal fixation of os acromion fracture-separation as a component of a floating shoulder injury: A case report - Corrected Proof

Robert P. Lyons — 2010-08-13

Os acromiale is an anatomic variant that is rarely implicated as the source of pain. The discovery of an os acromiale in patients reporting trauma is frequently incidental. Although the prevalence of symptomatic os is unknown, it has been suggested that the area of fibrous union or nonunion of the os fragment may become painful after minor trauma.

Acute, avulsion fractures of the medial epicondyle while throwing in youth baseball players: A variant of Little League elbow - Corrected Proof

2010-08-06

Hypothesis: The young throwing athlete is susceptible to medial elbow injury due to valgus overload. We hypothesized that this injury can occur during the throwing motion with an acute episode of medial elbow pain resulting in an inability to effectively participate in throwing activities. In addition, appropriate treatment of acute, medial epicondyle avulsion fractures in baseball players can result in an asymptomatic elbow with subsequent return to play within a year of injury.Materials and methods: A case series of all youth baseball players with medial epicondyle avulsion fractures that occurred while throwing were identified. We studied several variables, including demographics, adherence to USA Baseball youth pitching recommendations, clinical history, radiographic findings, treatment, and outcome.Results: Eight skeletally immature baseball players, who were a mean age of 13 years (range, 11-15 years), presented with medial epicondyle fractures that occurred while throwing. All 8 players experienced sudden pain during throwing, and all 5 players with appropriate age and position qualifications did not conform to the USA Baseball youth pitching recommendations. Anteroposterior radiographs documented average fracture displacement of 5.1 mm (range, 2.5-10 mm). Five of 8 players had 5 mm or less of displacement and were selected for nonoperative treatment. Three of 8 players had more than 5 mm of displacement and underwent open reduction and internal fixation. All players were able to return to play at an average of 7.6 months (range, 4-10 months).Discussion: Medial epicondyle avulsion fractures can occur with a characteristic acute presentation while throwing in youth baseball players. Prevention may be possible when conforming to established USA Baseball youth pitching recommendations. Once an acute medial epicondyle avulsion fracture occurs, these injuries may be managed using published treatment algorithms, with successful return to play in less than 1 year.

Repair results of 2-tendon rotator cuff tears utilizing the transosseous equivalent technique - Corrected Proof

Paul M. Sethi, Benjamin C. Noonan, James Cunningham, Evan Shreck, Seth Miller — 2010-08-05

Background: The purpose of this study was to examine the healing rate of 2-tendon rotator cuff tears repaired by the use of a transosseous-equivalent (TOE) suture bridge technique.Materials and methods: Forty-three patients with combined supraspinatus and infraspinatus tendon tears underwent arthroscopic repair using TOE technique. Forty of these patients were then evaluated by MRI and clinical exam at a minimum of 1-year follow-up to determine the rate of healing of the repair and clinical outcomes associated with healing.Results: Eighty-three percent of the repairs demonstrated intact rotator cuff repairs at a mean of 16 months post-op. Larger tears (3.5 vs 2.8 cm) were associated with failure (P = .01), as was more advanced fatty infiltration (Goutallier 1.3 vs 0.3, P = .01). Age was not different between intact and nonintact tendons. Strength was the only clinical finding that differed between intact and nonintact tendons.Conclusion: Two-tendon tears of the rotator cuff can heal at a high rate with the use of TOE suture bridge repair technique. Furthermore, tear size and Goutallier grading were negatively correlated with postoperative healing. The incremental improvement in the rate of observed rotator cuff healing still does not translate to statistical differences in the objective shoulder scoring systems.

Correlation of psychomotor findings and the outcome of a physical therapy program to treat scapular dyskinesis - Corrected Proof

2010-08-05

Background: This pilot study was performed to investigate the influence of psychomotor skills on the outcome of a specific nonoperative program (scapular dyskinesis-program) to treat scapular dyskinesis.Materials and methods: Fifteen patients (group A) with positive and 11 patients (group B) with a negative outcome after physical therapy were included. To test the psychomotor skills of the patients the Motorische Leistungsserie (MLS) was used. The test results of the patients of group A were then compared with those of group B.Results: For 2 parameters, a significant correlation could be detected. However, due to the small sample size, a clear but statistically insignificant difference could be found for several other factors.Conclusion: We, therefore, hypothesize that psychomotor skills testing is a potential method to predict the outcome of nonoperative treatment for scapular dyskinesis. Further investigations with a larger sample size are necessary to confirm this assumption.

The timing of rotator cuff repair for the restoration of function - Corrected Proof

Steve A. Petersen, Todd P. Murphy — 2010-08-05

Introduction: This study was developed to test the hypothesis that there is a period in which a painful, traumatic rotator cuff tear, with associated weakness and the inability to abduct above shoulder level, should be repaired to allow for improvement in function.Methods: Forty-two consecutive, prospectively followed patients met the criteria for entrance into this study. Of those, 36 patients were available for a minimum 9 months follow-up (average, 31 months; range, 9–71) by office visit. Patient outcomes were measured using the UCLA End-Result and ASES scoring systems. Patient variables, including time from injury to repair, tear size, degree of preoperative fat infiltration, patient satisfaction, and improvement in pain, were evaluated for their association with surgical outcome using independent t testing. Time to repair was evaluated at 0–2 months, 2–4 months, and greater than 4 months.Results: Pain scores improved from 7 to 1.4 (P < .01) and active elevation improved from 55° to 133° (P < .01). UCLA/ASES scores improved from 8/30 to 26/79, respectively (P < .01, P < .01). All but 2 of the 36 patients were satisfied with their result. Preoperative fatty atrophy did not correlate with postoperative function. Rotator cuff tear size had no influence on patient outcome if repaired before 4 months. Massive tears repaired after 4 months had the worst outcome.Conclusion: Our results emphasize that the treatment outcome for traumatic rotator cuff tears of all sizes, with associated weakness, is not compromised up to 4 months after their injury.

Delayed valgus instability and proximal migration of the radius after radial head prosthesis failure - Corrected Proof

Roger P. van Riet, Bernard F. Morrey — 2010-08-05

Radial head resection has yielded excellent long-term results in isolated radial head fractures. Most comminuted radial head fractures are complicated by associated lesions, however, and acute radial head replacement is often indicated in these patients. Metal radial head prostheses have become the standard treatment of irreparable radial head fractures with associated lesions to the elbow or forearm that render the elbow or forearm unstable. The prosthesis has been postulated to act as a temporary spacer while the injured soft tissues heal. Subsequent removal of the prosthesis to decrease pain and increase mobility yielded good to excellent results in previously reported cases. However, we present a patient whose in whom the soft tissues did not heal over a prolonged period, leading to a poor result after removal of a radial head implant.

A comparison of perioperative outcomes in patients with and without rheumatoid arthritis after receiving a total shoulder replacement arthroplasty - Corrected Proof

2010-07-26

Hypothesis: The long-term survival rate of total shoulder arthroplasty (TSA) is comparable to hip and knee arthroplasty. Although TSA is considered a safe and effective procedure with low complications in patients with osteoarthritis and rheumatoid arthritis (RA), data are lacking on perioperative complications. Complication rates and hospital disposition differences between patients with and without RA who underwent TSA were investigated. We hypothesized that RA patients would have poorer perioperative outcomes after TSA.Materials and methods: Data from the Nationwide Inpatient Sample was used to capture 25,398 patients between 1988 and 2005 who underwent TSA. Of these, 1,186 patients had a primary diagnosis of RA and were compared with 24,212 patients without RA. Analyses addressed perioperative complications and hospital disposition factors using bivariate and logistic regression models.Results: Overall complication rates were exceptionally low in both groups. Hospital disposition factors were significantly different between the 2 groups. The RA cohort had shorter average lengths of stay, higher likelihood of routine discharge, and lower inflation-adjusted cost before and after adjustment for covariates.Discussion: The occurrence of complications in the perioperative setting was less than 1% for both study groups in most variables investigated, and there were only minimal differences in perioperative complications between the groups. The significant differences in hospital disposition factors suggest that patients with RA may have less complex hospital stays and may be more comfortable being discharged under their own care. Recent studies describing the overall improvement in the management of patients with RA may also help explain these findings.Conclusions: The findings suggest that the perioperative complications of a total shoulder replacement for patients with and without RA are similar. Contrary to our expectations, TSA patients with RA had shorter and less costly hospital stays and were more likely to have routine discharge. Complications are likely more long-term in nature than detected in this study and require longer follow-up beyond perioperative periods for fruition.

A quantitative method for determining medial migration of the humeral head after shoulder arthroplasty: Preliminary results in assessing glenoid wear at a minimum of two years after hemiarthroplasty with concentric glenoid reaming - Corrected Proof

2010-07-26

Hypothesis: Glenoid erosion and medial migration of the humeral head prosthesis have been observed after most types of shoulder arthroplasty. A method of measuring the change in humeral head position with time after shoulder prosthetic arthroplasty was applied it to 14 shoulders that underwent humeral hemiarthroplasty with concentric glenoid reaming. We hypothesized that the measurement technique would be reproducible and that the rate of wear would be small in the series of shoulders studied.Materials and methods: Standardized anteroposterior and axillary radiographs were obtained after surgery. Two examiners measured the position of the humeral head center in relation to scapular reference coordinates for the anteroposterior and axillary projections and plotted these values against time after surgery. The change in position was characterized as the slope of this plot. Shoulders were included if there were at least 3 sets of postoperative films, the last being at least 2 years after surgery.Results: The slopes measured by the 2 examiners agreed within 0.5 mm/y for the anteroposterior and the axillary projections. For the series of shoulder arthroplasties, the rate of movement of the head center toward the scapula was less than 0.4 mm/y for either examiner in either projection.Discussion: Medial migration is a concern after any type of shoulder arthroplasty, whether a hemiarthroplasty, a biological interpositional arthroplasty, or a total shoulder arthroplasty. Quantifying the rate of medial migration over time after shoulder arthroplasty is an important element of clinical follow-up.Conclusions: This is an inexpensive, practical, and reproducible method that can be used to determine the rate of medial migration of the humeral head on plain radiographs after shoulder arthroplasty. The average rate of medial migration in the shoulders in this study was small.

Tension, abduction, and surgical technique affect footprint compression after rotator cuff repair in an ovine model - Corrected Proof

Brett M. Andres, Patrick H. Lam, George A.C. Murrell — 2010-07-26

Introduction: Shoulder motion after rotator cuff repair may result in changes in tension and contact pressure at the repair site. Our goal was to determine how tension and motion affect a repair and what type of repair best tolerates these variables.Methods: Rotator cuff tears were created ex vivo in 30 ovine shoulders divided into 5 groups: single-row repair, double-row repair, tension-band repair, suture bridge repair, and double-row tension-band repair. A pressure probe was passed through a hole created in the footprint to dynamically measure footprint pressure. The rotator cuffs were repaired, and contact pressure was measured with variable tension placed on the repaired tendon from 10 to 30 N and variable shoulder abduction from −10° to +10°. Repair strength was determined by use of a pull-to-failure test.Results: Increasing tension on the repaired tendon resulted in an increase in contact pressure whereas increasing the abduction angle resulted in a decrease in contact pressure in all 5 groups. For all abduction and tension combinations, the suture-bridge and double-row tension band groups recorded the highest contact pressures (P < .05), followed by the tension-band, single-row, and double-row repairs. Load to failure was greatest for the 2 double-row techniques, followed by the tension-band, suture-bridge, and single-row repairs.Discussion: Contact pressure increases as tension increases across the repair and decreases as the shoulder is abducted. The double-row tension-band rotator cuff repair showed the best combination of contact pressure and repair strength.

Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness? - Corrected Proof

2010-07-26

Hypothesis: Conservative rehabilitation after arthroscopic rotator cuff repair does not result in long-term stiffness and improves rates of tendon healing.Materials and methods: We retrospectively evaluated 43 patients with full-thickness rotator cuff tears who underwent a standardized, conservative protocol of full-time sling immobilization without formal therapy for 6 weeks after arthroscopic repair. At 6 to 8 weeks of follow-up, we categorized patients as “stiff” if they demonstrated forward elevation of less than 100° and external rotation of less than 30° passively; all others were designated “nonstiff.” Active range of motion in forward elevation, external rotation, and internal rotation was assessed at 3 months, 6 months, and 1 year. American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores were assessed at 1 year. Follow-up magnetic resonance imaging (MRI) was obtained in all patients to assess tendon healing.Results: Ten patients (23%) were considered stiff after rotator cuff surgery. At 1 year, there was no difference in mean forward elevation (166° vs 161°, P = .2), external rotation (62° vs. 58.4°, P = .5), or internal rotation (T7.4 vs T8.2, P = .07) between the stiff and nonstiff groups, respectively. There were no differences in final ASES (83 vs 79, P = .57) and Constant-Murley scores (77 vs. 74, P = .5). Repeat MRI suggested a trend toward a lower retear rate among the stiff patients (70% intact in stiff group vs 36% in nonstiff group, P = .079). Two clinically significant cuff retears occurred in the nonstiff cohort.Discussion: Concerns for recalcitrant stiffness have led some to favor early postoperative therapy. We found that early restriction of motion did not lead to long-term stiffness after arthroscopic rotator cuff repair, even in patients who were clinically stiff in the early postoperative period.Conclusions: Sling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in increased long-term stiffness and may improve the rate of tendon healing.

A biomechanical study of posterior glenoid bone loss and humeral head translation - Corrected Proof

2010-07-26

Background: Results of shoulder arthroplasty have been reported to be inferior with posterior glenoid wear and accompanying subluxation of the humeral head. The purpose of this study was to examine the effect of posterior glenoid wear on posterior subluxation of the humeral head.Material and methods: A custom loading device was used to simulate physiologic loading conditions in 8 cadaver shoulders with the humerus positioned at neutral, forward flexion, and extension. Three-dimensional motion analysis recorded humeral head translation with respect to the scapula at each humerus position after removing posterior glenoid bone in 5° increments. The magnitude of humeral head translation was analyzed with 2-way ANOVA to determine the effects of arm position and glenoid condition.Results: Glenoid condition and arm position in the transverse plane significantly influenced head translation (P < .0001). With the humerus at neutral, posterior translation became significant after 20° of posterior bone removal (P < .05). However, with the humerus in forward flexion, posterior translation became significant at only 5° of posterior bone removal (P < .001). No significant differences in translation were detected for posterior defects up to 25° with the arm in extension.Conclusion: Posterior humeral head translation increased significantly with 5° of posterior glenoid bone loss, which equates to approximately 2.5° of glenoid retroversion. Awareness that humeral head translation may be seen with small amounts of retroversion should be recognized during preoperative planning for shoulder arthroplasty and when counseling the patient with regard to expected outcomes.

Subacromial pressures vary with simulated sleep positions - Corrected Proof

2010-07-26

Hypothesis: Subacromial impingement is one of the underlying factors of rotator cuff pathologies and is linked to increased subacromial pressures. Because humans spend about one-third of their life sleeping, we hypothesized that distinct shoulder positions while sleeping may considerably influence nocturnal subacromial pressures. Consequently, atrophy and rupture can affect tendon healing after rotator cuff repair, thus potentially discrediting the outcome of surgery.Materials and methods: We determined the subacromial pressures acting on the rotator cuff in the 4 most common sleep positions and related these pressures to the mean arterial blood pressure and physical examination findings in 20 healthy volunteers.Results: Subacromial pressures were significantly lower in participants sleeping preferably in a supine position than in participants sleeping in side or prone positions (P < .005).Discussion: As tendon perfusion is crucial for tendon-to-bone healing during postoperative physical therapy after rotator cuff reconstruction and for prevention of additional damage to healthy or already torn cuffs, potential clinical relevance may emerge from the present study.Conclusion: Distinct shoulder positions considerably influence subacromial pressures. Our findings may be considered in physiotherapeutic concepts after rotator cuff surgery.

Shoulder arthroscopy in patients with a cardiac pacemaker or defibrillator: A case report and discussion of perioperative management - Corrected Proof

David S. Wellman, Brett W. McCoy, Steven D. Levin, Bradley P. Knight — 2010-07-26

The prevalence and severity of rotator cuff tears increase with age. After the age of 60, 50% of adults show signs of rotator cuff disease, and in the ninth decade, the prevalence reaches 80%. As we see an increase in elderly patients leading active lifestyles, there is a concomitant increase in patients who present with shoulder ailments that require surgical treatment. Surgeons who treat shoulder problems in this older subset of patients must be prepared to address complex medical comorbidities.

Forces across the middle of the intact clavicle during shoulder motion - Corrected Proof

2010-07-20

Hypothesis: The optimal management of displaced middle third clavicle fractures is currently under investigation. Advances in fracture fixation technology have expanded the indications for operative fracture management. Data are currently unavailable regarding the normal forces and moments that occur in the middle clavicle with motion of the glenohumeral joint. This study tested our null hypothesis that active range of motion in internal rotation, external rotation, and abduction would produce a similar magnitude of force across the middle clavicle.Materials and methods: Clavicle forces were measured in 6 whole fresh frozen cadavers using a 6 degree-of-freedom load cell mounted to the middle third of the clavicle. The rotator cuff tendons were isolated, divided, and connected to a system of weights. The forces across the clavicle in 3 orthogonal directions were quantified during simulated active abduction, internal rotation, and external rotation.Results: There were statistically greater axial compressive force and torque in the clavicle during humeral abduction compared with internal or external rotation. During external rotation, there were statistically greater tensile forces compared with abduction or internal rotation. There were no statistical differences in the superior-inferior or anterior-posterior forces with the 3 motions studied.Discussion: Overall, active abduction caused the greatest increase in middle clavicle forces and torque. Abduction resulted in the most significant axial compressive force, whereas active external rotation caused the greatest tensile force across the intact middle clavicle.Conclusions: To our knowledge, these findings represent the first results describing the forces across the intact clavicle during glenohumeral motion. These data can be used to aid clinicians in treating these fractures, guide the design of future biomechanical studies, and develop rehabilitation protocols.

Results of concomitant rotator cuff and SLAP repair are not affected by unhealed SLAP lesion - Corrected Proof

Joo Han Oh, Sae Hoon Kim, Sang-ho Kwak, Chung Hee Oh, Hyun Sik Gong — 2010-07-16

Hypothesis: To verify the anatomic results of combined repair of a full-thickness rotator cuff tear and superior labral anterior and posterior (SLAP) lesion. In addition, we compared the anatomic and functional outcomes according to the status of the repaired SLAP lesion.Methods: We enrolled 61 patients who underwent cuff repair with concomitant SLAP repair and were available for both functional and radiologic outcome evaluation at least 1 year after the operation. There were 40 male and 21 female patients with a mean age of 57.4 years (range, 39-70 years). We measured various clinical outcomes and evaluated the structural outcomes of the rotator cuff and the superior labrum and rotator cuff using computed tomography arthrography at the final follow-up visit. We also evaluated the functional outcome according to anatomic healing of the superior labrum.Results: Labral healing to the bony glenoid was achieved in 49 patients (80.3%), and anatomic healing of the rotator cuff was observed in 44 patients (72.1%). The retear rate of the rotator cuff was not statistically different with respect to labral healing status. All functional outcomes improved significantly (P < .001), and there were no statistical differences in functional outcome with respect to postoperative healing of the superior labrum.Conclusions: An unhealed SLAP lesion did not preclude the successful outcome of concomitant rotator cuff repair. Therefore, repair of a concomitant SLAP lesion may not be an essential procedure for a successful outcome of a rotator cuff repair.

Bony avulsion of the medial ulnar collateral ligament in a gymnast: A case report - Corrected Proof

Robert C. Grumet, Nicole A. Friel, Brian J. Cole — 2010-07-16

The risk of injury in gymnastics is higher during periods of rapid growth and is directly related to the level of competition. Gymnasts spend an estimated 29% of their season altering their training routine as a result of injury. Most injuries in these athletes are the result of overuse, with upper extremity injuries occurring more frequently in male gymnasts and lower extremity injuries more often in females. Elbow injuries are relatively common in gymnasts due to the repetitive compressive varus and valgus stresses applied. These super-physiologic loads likely contribute to the development of osteochondritis dissecans of the capitellum and medial epicondylitis or apophysitis. Catastrophic injury, such as an acute dislocation, is frequently seen as a result of a missed move, a fall from the apparatus, or an improper dismount. Several case studies have described the extreme of these injuries, such as bilateral elbow dislocations, in a gymnast.

Bilateral Parsonage-Turner syndrome with unilateral brachialis muscle wasting: A case report - Corrected Proof

Alexander Van Tongel, Michael Schreurs, Frans Bruyninckx, Philippe Debeer — 2010-07-15

▪: ▪

Functional outcome and structural integrity following mini-open repair of large and massive rotator cuff tears: A 3-5 year follow-up study - Corrected Proof

2010-07-12

Background: Mini-open approach has been considered for years the gold standard for rotator cuff repairs. Nevertheless, the rate of tendon-to-bone healing, and that of cuff re-tear, still remains unclear.Methods: Between 2001 and 2004, 37 shoulders (32 patients) with a mean age of 54.8 years (range, 34-72) and a large or massive cuff tear were repaired with a mini-open procedure. At a minimum of 3 years postoperatively (range, 36-60 months), 27 shoulders (23 patients) underwent functional evaluation and US investigation of cuff integrity.Results: The rotator cuff was completely healed and watertight in 13 cases (48.1%), while recurrent defects were detected in the remaining 14 shoulders (51.9%). In 12 cases (92.5%), the recurrent tears were smaller and in 2 (7.5%) larger than the initial tear. Despite the high re-tear rate, the overall Constant and UCLA scores improved from of 38.4 to 72.1 and 11.2 to 29.4, respectively. However, only “large” re-tears were correlated with a worse functional outcome (P < .005). The preoperative tear size was negatively associated with tendon healing. Patients with an intact rotator cuff repair were, on average, 15 years younger (49.9) than those who sustained a tear recurrence (64.14) (P < .005).Discussion: Our results suggest that large and massive rotator cuff tears treated with mini-open technique using a tendon-grasping suture have a very satisfactory clinical outcome, despite a significant re-tear rate. Patient age, the size of the initial tear, as well as the size of a potential re-tear are factors affecting the final clinical outcome.

Does obesity affect early outcome of rotator cuff repair? - Corrected Proof

Surena Namdari, Keith Baldwin, David Glaser, Andrew Green — 2010-07-07

Background: Obesity is linked to major health conditions and poor surgical outcomes. The impact of obesity on self-perceived outcome after rotator cuff repair (RCR) is unclear.Materials and methods: We studied 154 patients who underwent RCR. Obesity was considered a body mass index (BMI) greater than 30. Preoperative and postoperative evaluations included the Disabilities of the Arm, Shoulder and Hand (DASH), Simple Shoulder Test, and visual analog scales for pain, function, and quality of life. Obese and control patients were compared for baseline demographics, surgical findings, and postoperative outcomes.Results: Our overall population had a mean BMI of 28.4 (95% confidence interval, 27.7-29.1). There were 57 obese patients (BMI >30) and 97 nonobese patients with 1- or 2-tendon rotator cuff tears. Mean follow-up was 54.8 weeks (range, 52.0-88.7 weeks). Preoperative DASH score was 45.2 for obese patients and 43.4 for control patients (P = .524). The mean improvement in DASH score was 30.7 for obese patients and 26.1 for nonobese patients (P = .152). There were no significant differences in the Simple Shoulder Test and visual analog scale scores. Worse follow-up DASH scores in both groups were associated with worker's compensation status (P = .003) and total comorbidities (P < .001). Multiple linear regression analysis showed that BMI (continuous) and obesity (dichotomous) were not significantly related to outcome after we controlled for confounding variables.Conclusions: Although obesity is considered a risk factor for poor postoperative outcomes after some surgical procedures, in our experience, obesity does not have an independent, significant effect on self-reported early outcomes after RCR.

Ulnar collateral ligament injuries of the elbow in professional football quarterbacks - Corrected Proof

2010-07-07

Background: Ulnar collateral ligament (UCL) injuries of the elbow can cause significant pain and disability in the overhead thrower. Most studies in the literature have focused on baseball players and demonstrated that surgical reconstruction is the most reliable way to allow these athletes to return to their previous level of performance. Little is known about whether or not surgical reconstruction is necessary for other types of elite throwing athletes. We hypothesize that professional football quarterbacks with UCL injuries of the elbow can return to competitive play after nonoperative management.Methods: The NFL Injury Surveillance System (NFLISS) was reviewed for any UCL injuries of the elbow in quarterbacks from 1994 to 2008, including the type and mechanism of injury, player demographics, method of treatment, and time to return to play.Results: A total of 10 cases of UCL injuries in quarterbacks were identified starting in 1994. Nine cases were treated nonoperatively and the mean return to play was 26.4 days.Conclusion: UCL injuries of the elbow are uncommon injuries in professional quarterbacks. This group of overhead athletes can be successfully treated nonoperatively, in contrast to baseball players, who more commonly need surgical reconstruction to return to competitive play. The difference between the 2 groups of overhead athletes is most likely secondary to biomechanics and demand.

Superior humeral head migration occurs after a protocol designed to fatigue the rotator cuff: A radiographic analysis - Corrected Proof

Jaclyn N. Chopp, John M. O'Neill, Kevin Hurley, Clark R. Dickerson — 2010-07-05

Hypothesis: Awkward postures and repetitive work have been suggested to lead to shoulder fatigue, which may in turn decrease the subacromial space. The aim of this study was to quantify changes in humeral head position relative to the glenoid after rotator cuff fatigue. We hypothesized that the humeral head would migrate superiorly with fatigue due to the inability of the rotator cuff muscles to balance the upward pull of the deltoid.Materials and methods: Four anterior-posterior radiographs (at 0°, 45°, 90°, and 135° of elevation in the scapular plane) of the glenohumeral joint were taken before and after a fatiguing task. The fatiguing task was a simulated job task intended to exhaust the entire rotator cuff.Results: The position of the humeral head with respect to the glenoid cavity was significantly affected both by arm elevation angle and fatigue state. In the prefatigued state, increasing arm elevation angle was related to superior translation until 90°, after which the humeral head moved inferiorly to a more central position. In the postfatigued state, the inability of the rotator cuff to centralize the humeral head led to increasing translations with higher elevations.Discussion: Superior humeral head migration was associated with the fatigued state. This implies that overhead or repetitive work, or both, may accelerate the development of subacromial impingement through reduction of the subacromial space.Conclusions: Continuous overhead work demonstrably created rotator cuff fatigue, which apparently inhibited the ability of the shoulder musculature to resist upward humeral translation.

Treatment of traumatic posterior sternoclavicular dislocations - Corrected Proof

Gordon I. Groh, Michael A. Wirth, Charles A. Rockwood — 2010-06-28

Background: Traumatic posterior sternoclavicular joint injuries are rare, but complications are common and include brachial plexus and vascular injury, esophageal rupture, and death.Materials and methods: The records of 21 patients treated at our institution for a posterior sternoclavicular injury were reviewed. All patients underwent a trial of closed reduction, which was effective in 8 patients (group I). The remaining 13 patients were treated with open reduction and sternoclavicular joint reconstruction (group II).Results: Closed reduction was more likely to be successful (P < .05) in dislocations treated within 10 days of injury. Patients were evaluated by use of the University of California, Los Angeles rating scale. Overall, 18 of 21 patients were graded as good or excellent. Patients treated with either open or closed reduction as their definitive management compared favorably in terms of ratings for pain, strength, and motion.Conclusion: Our experience suggests that closed reduction compares favorably with open reduction. Of patients treated, 38% required only closed reduction as their definitive treatment. In this series early closed reduction was successful and obviated the risks of surgery. Patients who in whom closed reduction failed obtained good results with operative treatment aimed at reconstruction of the costoclavicular ligaments.

Survival and radiographic analysis of a cementless fluted pegged glenoid component - Corrected Proof

Gordon I. Groh — 2010-06-21

Background: Aseptic loosening of glenoid components is a common problem associated with total shoulder arthroplasty and one cause for failure. A new cementless fluted glenoid component was developed and has shown excellent bony ingrowth in a canine model.Hypothesis: Clinical utilization of this cementless fluted pegged glenoid component in total shoulder arthroplasty would lower rates of radiolucent lines and aseptic loosening.Materials and methods: Between January 2005 and December 2007, 83 primary shoulder arthroplasties with a minimum of 2 years' follow-up were performed with the uncemented fluted pegged glenoid component. Radiographs and records were reviewed to determine stability and survival of the glenoid component.Results: All cementless fluted pegged glenoid components had survived at the most recent clinical follow-up. Radiographs showed no evidence of component loosening or radiolucent lines. Evidence of fingerlike projections of bone between the flanges of the implant was found in 24 cases (29%).Conclusions: A cementless fluted pegged glenoid component showed excellent initial clinical survival and integration. Further studies regarding continued durability of this component appear warranted.

Quantitative three-dimensional computed tomography measurement of radial head fractures - Corrected Proof

Thierry G. Guitton, Huub J. van der Werf, David Ring — 2010-06-21

Background: We developed a method to quantitatively analyze fracture fragment morphology on quantitative 3-dimensional computed tomography (3DCT) images in terms of size, shape, and articular surface area.Materials and methods: We analyzed 46 adult patients with a computed tomography scan of a fractured radial head with quantitative 3DCT. We defined an unstable fracture as complete loss of cortical contact of at least 1 fragment. Of the patients, 3 had a Mason type 1 fracture (all stable), 26 had a type 2 fractures (7 stable [27%] and 19 unstable [73%]), and 17 had a type 3 fracture (all unstable). The volume and articular surface area of each articular fracture fragment were measured. A small fragment was defined as having a volume of less than 100 mm3 or an articular surface of less than 100 mm2.Results: Partial head fractures (Mason type 2) (26 fractures) are usually multi-fragmented (19 of 26 [73%]) and often have small fragments by volume (32 fragments) and surface area (46 fragments) criteria, particularly when the fracture is displaced and unstable. Only 4 of the 17 patients (25%) with whole-head fractures (Mason type 3) had greater than 3 fragments, but 9 of 17 fractures (69%) with 3 or fewer fragments had small fragments.Conclusions: According to this initial application of quantitative 3DCT analysis, partial-head fractures are often complex and difficult to repair (small fragments), and most whole-head fractures have 3 or fewer fragments, but many of those fragments are small and may be difficult to repair.

Agreement study of radiographic classification of rotator cuff tear arthropathy - Corrected Proof

2010-06-17

Hypothesis: This study evaluated the intra-rater and inter-rater correlation of 3 commonly used x-ray image classifications and defined the clinical factors most correlated with a surgical recommendation for a hemiarthroplasty or a reverse total shoulder arthroplasty (RSA) for treatment of rotator cuff tear arthropathy (CTA). We hypothesized that specific radiographic criteria and clinical criteria would be most important and consistently used among experienced shoulder surgeons when determining the best surgical option for a particular patient.Methods: Four experienced orthopedic surgeons evaluated standard anteroposterior radiographs and the clinical examination of 37 shoulders with CTA. On each reading, they classified the grade of pathology using the Seebauer, Favard, and Hamada classifications. Using radiographic criteria alone, or with the clinical findings, each evaluator determined the recommended prosthetic treatment for each shoulder.Results: Intra-rater correlations for surgical recommendations using radiographic criteria ranged from 0.39 to 1.0 and improved in 3 of 4 evaluators when the clinical examination was included in the clinical decision. The inter-rater reliability using these same criteria were fair, at 0.32 for radiographic and .35 for radiographic and clinical data. The most significant radiographic factors associated with a surgical decision were the degree of humeral head superior migration and the escape of the humeral head from the coracoacromial arch. Clinical factors most associated with the decision for RSA were advanced age, loss of shoulder elevation, superior humeral head escape, and pseudoparalysis of the shoulder. Radiographic findings had a less significant effect on surgical recommendations when clinical factors were included.Conclusion: Clinical and radiographic criteria are needed for a decision for hemiarthroplasty or RSA in the treatment of CTA. A treatment algorithm based upon radiographic and clinical criteria is proposed.

Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015 - Corrected Proof

2010-06-16

Hypothesis: This study examined national trends and projections of procedure volumes and prevalence rates for shoulder and elbow arthroplasty in the United States (U.S.). This study hypothesized that the growth in demand for upper extremity arthroplasty will be greater than the growth in demand for hip and knee arthroplasty and that demand for these procedures will continue to grow in the immediate future.Materials and methods: The Nationwide Inpatient Sample (1993-2007) was used with U.S. Census data to quantify primary arthroplasty rates as a function of age, race, census region, and gender. Poisson regression was used to evaluate procedure rates and determine year-to-year trends in primary and revision arthroplasty. Projections were derived based on historical procedure rates combined with population projections from 2008 to 2015.Results: Procedure volumes and rates increased at annual rates of 6% to 13% from 1993 to 2007. Compared with 2007 levels, projected procedures were predicted to further increase by between 192% and 322% by 2015. The revision burden increased from approximately 4.5% to 7%. During the period studied, the hospital length of stay decreased by approximately 2 days for total and hemishoulder procedures. Charges, in 2007 Consumer Price Index-adjusted dollars, increased for all 4 procedural types at annual rates of $900 to $1700.Conclusion: The growth rates of upper extremity arthroplasty were comparable to or higher than rates for total hip and knee procedures. Of particular concern was the increased revision burden. The rising number of arthroplasty procedures combined with increased charges has the potential to place a financial strain on the health care system.

Integrity and function of the subscapularis after total shoulder arthroplasty - Corrected Proof

Jeffrey D. Jackson, Akin Cil, Jay Smith, Scott P. Steinmann — 2010-05-31

Background: Reported healing rates of a subscapularis tenotomy have been extremely variable in the literature. The purpose of this study was to document the subscapularis healing rate after subscapularis tenotomy using ultrasound, and to correlate healing with physical examination findings and shoulder internal rotation strength.Methods: Fifteen patients who underwent total shoulder arthroplasty due to unilateral osteoarthritis were evaluated after a minimum of 6 months follow-up with ultrasound, physical examination, and internal rotation strength testing. At surgery, a subscapularis tenotomy utilized to approach the shoulder. Postoperatively, no formal physical therapy program was utilized.Results: Seven of the 15 shoulders had a complete tear of the repaired subscapularis tendon based on ultrasound examination. The lift-off and abdominal compression tests correlated poorly with the ultrasonographic condition of the subscapularis. The bear hug test using dynamometry did correlate with tendon integrity. Patients with a subscapularis tear after arthroplasty experienced significant weakness in isometric (P = .01) and isokinetic (P < .01) internal rotation strength testing, as well as significantly worse DASH scores (P = .04). No patient demonstrated anterior subluxation on examination or by radiograph.Conclusion: Subscapularis tear after total shoulder arthroplasty is a common finding, which cannot be diagnosed reliably by physical examination or radiographs. In this population, subscapularis integrity did not correlate with pain or subjective patient outcome. Failure to heal the subscapularis tenotomy is probably more common than has been previously reported based on only physical examination testing.

Arthroscopic rotator interval closure in shoulder instability repair: A retrospective study - Corrected Proof

2010-05-17

Background: Arthroscopic Bankart repair (ABR) is a standard treatment for recurrent anterior shoulder instability. Young age, hyperlaxity, loss of bone stock and multidirectional or voluntary type of instability are all associated with failure of this procedure. Rotator interval laxity is associated with shoulder instability, whereas rotator interval closure increases humeral head stability and reduces shoulder range of motion.Methods: The records of patients with recurrent anterior shoulder dislocations who underwent ABR with or without arthroscopic rotator interval closure (ARIC) in our department between 1999 and 2007 were reviewed. Rates of recurrent dislocation or symptomatic subluxation as well as functional outcome were evaluated using Walch-Dupley score.Results: Three (8.1%) of the 37 ABR+ARIC patients (age 19-44 years, 32 males) had re-dislocated their shoulder at 42±16 months following the procedure, all of which had systemic joint hyperlaxity. Six (13%) of the 46 ABR patients (age 19-39 years, 42 males) had re-dislocated their shoulder at 13±14 months, three of which had systemic joint hyperlaxity and dislocated their shoulder within 1 year following the operation. Systemic joint hyperlaxity (28% of ABR and 41% of ABR+ARIC patients) was significantly associated with recurrent dislocation and poor functional outcome. ABR+ARIC patients had slightly more limited range of motion with similar good and excellent functional results (75%) at final follow up time.Conclusions: Systemic joint hyperlaxity is a risk factor for failure of ABR. When ARIC is performed in combination with ABR, it may have an additive effect on shoulder stability.

The hybrid technique: Potential reduction in complications related to pins mobilization in the treatment of proximal humeral fractures - Corrected Proof

2010-05-10

Background: Proximal humeral fracture fixation has a high incidence of complications especially when pins are used in elderly patients. In 2005, we introduced a new technique that augmented osteosutures by using 2.5-mm fully threaded pins and an external fixator (hybrid technique). The purpose of this study is to compare the outcomes of the hybrid technique (HT) with traditional pins fixation.Methods: A prospective nonrandomized study was organized on 2 consecutive series of patients: 51 patients treated with percutaneous fixation using 2.5-mm terminally threaded pins and 55 patients treated with the Hybrid technique. In both groups, an open reduction and osteosutures augmented with percutaneous fixation was used when closed reduction was insufficient to provide anatomical reduction. The patients were assessed at 6- and 12-month follows-ups using DASH score, Constant score, and Modified Constant score (MCS).Results: Sixteen patients treated with traditional pins experienced complications compared to 6 patients in the HT group (P = .006). The revision rate was 19% for the traditional pins group and 4% for the HT group (P = .04). Pins migration affected 8 patients in the traditional pins group and 1 case in the hybrid group (P = .01). The MCS at the 12-month follow-up was 89 ± 9 in the HT group and 77 ± 14 in the traditional pins group (P = .03). The MCS was negatively affected by complications and malreduction (P = .001).Conclusion: The study suggests that the HT is a valuable option for the treatment of proximal humeral fractures. It has benefits compared to the traditional technique.

Generalized ligamentous laxity as a predisposing factor for primary traumatic anterior shoulder dislocation - Corrected Proof

Jaskarndip Chahal, Jeff Leiter, Michael D. McKee, Daniel B. Whelan — 2010-05-10

Hypothesis: The purpose of this study was to determine whether generalized ligamentous laxity and increased shoulder external rotation represent predisposing factors for primary traumatic anterior shoulder dislocation in young, active patients. We hypothesized that generalized ligamentous laxity and increased shoulder external rotation would be more common in individuals with first-time traumatic shoulder dislocations compared with controls.Materials and methods: This retrospective case-control study examined hyperlaxity and shoulder external rotation >85° in 57 consecutive individuals (age <30 years) who sustained a primary traumatic anterior shoulder dislocation between 2003 and 2006. The Hospital Del Mar Criteria (battery of 10 clinical examination maneuvers) was used to measure generalized ligamentous laxity, which was determined to be present by overall scores exceeding 4/10 for men or 5/10 for women. The control group comprised 92 age-matched university students without a history of shoulder dislocation or anterior cruciate ligament injury.Results: Generalized ligamentous laxity was present in 33.3% of the cases compared with 15.2% of controls (P = .014). Increased contralateral shoulder external rotation (>85°) was observed in 38.6% of the study group compared with 22.8% of controls (P = .043). Men who had dislocated their shoulder were 6.8 times more likely to demonstrate generalized ligamentous laxity and increased shoulder external rotation compared with age and sex matched controls (P = .003).Discussion: Identifying hyperlax individuals may allow for shoulder-specific proprioceptive training.Conclusion: Generalized joint laxity and increased external rotation in the contralateral shoulder were more common in patients who had sustained a primary shoulder dislocation.

Glenoid version: How to measure it? Validity of different methods in two-dimensional computed tomography scans - Corrected Proof

2010-05-10

Hypothesis: Recognition of the glenoid version is important for evaluation of different pathologies such as degenerative wear, shoulder instability, or congenital deformity. Surgical strategies can change significantly in the presence of major retroversion. There is no consensus on the method to use to evaluate version. This study compared different measurement strategies in 116 patients with shoulder computed tomography (CT) scans. We hypotheses that the methods will give different value for evolution.Methods: Shoulder axial CT images were reviewed, and the image inferior to the base of the coracoid was selected. The glenoid version was measured according to the Friedman method and the scapula body method. Three orthopedic surgeons independently examined the images 2 times, and intraobserver and interobserver reliability was calculated using intraclass correlation (ICC).Results: Group 1 (n = 53): The average glenoid version was significantly different between the 2 measurement techniques for all 3 observers, with an average of –7.29° for the scapula body method and –10.43° for Friedman method. For group 2 (B2 glenoid group, n = 63): The most reliable method for measurement of B2 glenoid (glenoid with posterior erosion) version was the association of the Friedman line for the scapula axis and the intermediate glenoid line, with excellent intraobserver reliability (ICC > 0.957) and interobserver reliability (ICC = 0.954).Discussion: The glenoid version measurement is reliable on a 2D CT Scan. According to correlation found in our paper and those of the literature it seems that there is no advantage on 3D CT Scan to assess version in terms of reliability of measures.Conclusion: Combining the Friedman method to determine the scapula axis with an intermediate glenoid line in B2 glenoid yield the most reliable measurements.

Surgical treatment of chronic acromioclavicular dislocations: A comparative study of Weaver-Dunn augmented with PDS-braid or hook plate - Corrected Proof

2010-05-10

Background: The objective was to evaluate the Weaver-Dunn procedure (W-D) for chronic acromioclavicular joint dislocation augmented with a temporary hook plate or braided polydioxanone (PDS) loop suture.Methods: Retrospective comparative study of all patients treated for chronic acromioclavicular joint dislocation 1995-2006; 47 out of 52 included patients were re-examined. Twenty-three patients were operated with W-D augmented with PDS-braid and 24 patients with W-D and a temporary hook plate. Thirty-six were re-examined and new radiographs were taken, while 11 patients were evaluated over the phone.Results: The mean Constant score was 85 for the PDS group and 75 for the hook plate group (P = .21). There was no difference in outcome between the groups, according to the mean SPADI (P = .19), QuickDASH (P = .06), or Subjective Shoulder Value (P = .13). The patients in the hook plate group had more pain during movement (P = .003) at Visual Analogue Scale. Furthermore, there was no difference in the degree of subluxation after surgery between the PDS group and the hook plate group (P = .80).Conclusion: Reconstruction of chronic acromioclavicular joint dislocations restores good shoulder function and results in satisfied patients. Patients treated with the hook plate had more pain during movement and rest at the follow-up. The more rigid hook plate had no advantage and did not improve functional outcome. Furthermore, the extraction of the hook plate results in an additional surgical procedure.

A method for documenting the change in center of rotation with reverse total shoulder arthroplasty and its application to a consecutive series of 68 shoulders having reconstruction with one of two different reverse prostheses - Corrected Proof

2010-05-03

Background: Reverse shoulder arthroplasty changes the center of rotation (COR) of the glenohumeral joint and in doing so affects the resting tension in the deltoid and residual cuff muscles, as well as their respective moment arms. The purpose of this study was to assess the change in COR from the preoperative to postoperative state in a group of patients undergoing reverse shoulder arthroplasty.Materials and methods: The position of the COR in relation to a scapular coordinate system was determined for the anteroposterior and axillary radiographs before and after reverse total shoulder arthroplasty for 68 shoulders (63 patients) receiving either a Delta prosthesis or an Encore Reverse Shoulder Prosthesis.Results: Preoperatively, the COR was superiorly displaced a mean of 9 ± 7 mm from the origin of the coordinate system. For all shoulders, the postoperative COR was inferiorly displaced by 12 mm to a position 3 ± 3 mm below the coordinate origin (P < .001) and medially displaced by 27 ± 4 mm from the coordinate origin (P < .001) in the anteroposterior projection. For the shoulders receiving the Delta prosthesis, the COR was inferiorly displaced by 2 ± 3 mm from the coordinate origin, whereas it was inferiorly displaced by 7 ± 3 mm with the Encore prosthesis (P < .001). The COR was medially displaced by 28 ± 4 mm with the Delta prosthesis and by 19 ± 3 mm with the Encore prosthesis (P < .001).Conclusions: The position of the COR relative to the scapula is significantly altered by reverse shoulder arthroplasty and is significantly different for 2 different implant designs.

Outcomes of distal deltoid release for symptomatic cuff-tear arthropathy - Corrected Proof

Raffaele Scapinelli — 2010-04-26

Hypothesis: The author designed release and recession of the distal deltoid to decompress the subacromial space and possibly provide better shoulder function in patients with cuff-tear arthropathy. The indications include elderly low-demand patients in whom this condition was the cause of chronic unremitting and intractable pain with severe functional impairment of the shoulder.Materials and methods: A cohort of 22 patients with cuff-tear arthropathy, who were an average age of 73 years (range, 53-78 years), underwent distal deltoid release and recession. Clinical follow-up averaged 5.3 years (range, 2-7 years). A modified University of California, Los Angeles (UCLA) Shoulder Rating Scale was used.Results: No complications occurred. At final follow-up the clinical results were graded as excellent in 15 patients (68.2%), good in 4 (18.2%), fair in 1, and poor in 2. The most striking and gratifying result was pain relief, but active range of motion also significantly increased, leading to functional improvements and satisfaction. Muscular strength slightly improved or remained the same compared with preoperative status. In many cases, postoperative radiographs showed widening of the subacromial space, with no or only slight progression of glenohumeral joint osteoarthritis.Conclusion: Distal deltoid recession is a less invasive, extra-articular procedure that may be considered an alternative to a shoulder prosthesis and other surgical options, including muscle transfers, in patients with cuff-tear arthropathy.

Infraspinatus strength assessment before and after scapular muscles rehabilitation in professional volleyball players with scapular dyskinesis - Corrected Proof

2010-04-26

Hypothesis: This study tested the hypothesis that infraspinatus strength in professional volleyball players can be assessed with the scapula free (infraspinatus strength test, IST) and with the scapula retracted (infraspinatus scapula retraction test, ISRT) before and after scapular musculature training.Materials and methods: A prospective study was performed in 31 professional volleyball players. Isometric strength (kg) of the infraspinatus with IST and with ISRT was recorded by a handheld dynamometer and compared with the values found after 3 and 6 months of rehabilitation. Magnetic resonance imaging was performed to exclude articular and cuff pathology. Pain scores were assessed using a visual analog scale.Results: The mean increase in the force values of IST was statistically significant after 3 months (P < .01) and 6 months (P < .001) of rehabilitation. The mean difference between IST and ISRT decreased from 4.72 ± 0.007 before rehabilitation to 1.2 ± 0.26 at 3 months and to 0.4 ± 0.006 at 6 months. The mean score for pain was 2.4 ± 1.8 at 3 months and 2.6 ± 1.4 at 6 months.Discussion: Acquired scapular dyskinesis in overhead athletes can lead to the rotator cuff weakness. Inhibition due to pain and the negative biomechanic effect of scapular dyskinesis results in specific infraspinatus dysfunction that arise with the ISRT.Conclusions: ISRT is practical and consistent to assess the infraspinatus strength in overhead athletes with scapular dyskinesis. A functional rehabilitation protocol, designed to restore scapular muscles balance and shoulder mobility, is essential in the training program to prevent shoulder dysfunction and improve sports performance.

Osteosynthesis for longstanding nonunion of the lateral humeral condyle in adults - Corrected Proof

Junichi Miyake, Kozo Shimada, Takashi Masatomi — 2010-04-19

Hypothesis: Osteosynthesis for longstanding nonunion of the lateral humeral condyle in adults has a high rate of complications, including failure of bony union and restriction of elbow motion. We hypothesized that rigid fixation may contribute to higher union rate and the placement of the condyle fragment with proper tilting may minimize the reduction of elbow motion.Materials and methods: Ten patients were treated with osteosynthesis. Average age at operation was 38.6 years. Three patients had dysfunction of the ulnar nerve, 2 experienced pain, and 5 had both presentations. According to Toh et al's radiographic criteria, nonunion was categorized as Group 1 in 2 patients and Group 2 in 8 (J Bone Joint Surg Am 2002;84:593-598). We performed osteosynthesis with iliac bone graft and ulnar nerve anterior transposition, with efforts to fix the fragment rigidly and to manage the fragment position properly.Results: Osseous union was achieved in all 8 Group 2 patients, while 1 Group 1 case showed delayed union and the other did not achieve union. Pain resolved and ulnar nerve symptoms improved in all cases. In 9 patients with union, total arc of motion was reduced by an average of 20°. The preoperative mobility of the condyle fragment determined by maximum flexion and extension lateral radiographs had a correlation to the postoperative loss of motion (P = .047); however, loss of motion was less than that expected by radiographs.Conclusion: Osteosynthesis appears to be indicated for Group 2 nonunion with pain. Rigid fixation with care of the position of the fragment is important for the good outcomes.

Delamination tearing of the rotator cuff: Prospective analysis of the influence of delamination tearing on the outcome of arthroscopically assisted mini open rotator cuff repair - Corrected Proof

Graeme A. MacDougal, Chad R. Todhunter — 2010-04-14

Background: Limited information regarding the effect of delamination tearing on the outcome of rotator cuff repair is available in the literature. Studies have reported equally good results for rotator cuff repair using an open, mini-open, and arthroscopic repair techniques. Negative results have been reported for arthroscopic rotator cuff repair when delamination is present. The purpose of this study was to assess the affect of delamination on the outcome of the arthroscopically assisted mini-open technique.Materials and method: Two-hundred sixty-three consecutive operations were followed prospectively in this study. All underwent arthroscopically assisted mini-open repairs by a single surgeon. Patient demographics, compensation status, and tear characteristics were investigated. Variables were compared using the Western Ontario Rotator Cuff Index (WORC) pre-operatively and at 1 and 2 years postoperative.Results: The incidence of delamination was 71% of rotator cuff tears. Patient demographics did not affect the incidence of delamination. The presence of delamination did not affect the outcome of mini-open rotator cuff repair.Conclusion: We believe this technique is better able to produce reliable outcomes in the presence of delamination tearing.

Clinical and radiographic analysis of a partially cemented glenoid implant: Five-year minimum follow-up - Corrected Proof

R. Sean Churchill, Christopher Zellmer, Herbert J. Zimmers, Robert Ruggero — 2010-04-12

Hypothesis: This study reviewed 20 consecutive shoulders that underwent total shoulder arthroplasty with a partially cemented glenoid component at a minimum follow-up of 5 years. We hypothesized that bone growth between the fins of the component would result in improved glenoid fixation and reduced lucent line formation.Methods: Patients were evaluated with the Simple Shoulder Test (SST), Constant scores, and radiographs. Postoperative radiographs taken at 6 weeks and 5 years were compared. Independent evaluators assigned every glenoid a lucency grade from 0 (no lucency) to 5 (gross lucency) and assessed the central peg for bone presence between the fins.Results: Mean SST and Constant scores were 11.1 and 82.4, respectively. Mean lucency scores increased from 0.1 to 0.3 from 6 weeks to the 5-year follow-up (P = .05). At the 5-year follow-up, 15 of 20 patients had similar or increased bone presence between the central peg fins, and none had a worsening lucency score. The 5 patients with decreased or absent bone presence had worsening lucency scores, from a mean of 0.2 to 1.0 (P = .05). There was no difference in SST score (P = .54) or Constant score (P = .37) between the two groups.Conclusions: This partially cemented glenoid component had low rates of lucency at the 5-year follow-up. Similar or increased bone growth between the fins of the central peg was associated with no progression of glenoid lucencies. Decreased or absent bone presence between the fins at follow-up correlated with slight advancement of glenoid lucent lines.

Reverse shoulder arthroplasty in patients with rheumatoid arthritis - Corrected Proof

2010-04-05

Background: The purpose of this study was to describe the pathoanatomy of patients diagnosed with rheumatoid arthritis and rotator cuff deficiency and report their outcomes following reverse shoulder arthroplasty.Methods: Twenty-one shoulders were evaluated prospectively. Nine had no prior surgery, 9 had a failed rotator cuff repair, and 3 had a failed arthroplasty. Patients were followed for a minimum of 2 years (average, 36 months). All patients had preoperative radiographs and 19 shoulders had an MRI or CT available for evaluation of muscular and bony deficiency. Radiographs at most recent follow-up were evaluated for loosening and scapular notching.Results: All outcome measures improved significantly: ASES scores improved from 28 preoperatively to 82 postoperatively (P < .0001); SST scores improved from 1 to 7 (P < .0001); VAS pain scores improved from 7 to 1 (P < .0001); VAS function scores improved from 3 to 6 (P=.0058); elevation improved from 52° to 126° (P < .0001); abduction improved from 55° to 116° (P=.0002); external rotation improved from 19° to 33° (P=.02); and internal rotation improved from S1 to L4 (P=.02). Twelve patients rated their outcome as excellent, 6 as good, 2 as satisfactory, and 1 as unsatisfactory. Severe glenoid erosion was seen in 10 of the shoulders and 5 of the defects required structural grafting. Three patients (14%) sustained a complication that required reoperation: 2 for infection and 1 for periprosthetic fracture.Conclusions: In patients with rheumatoid arthritis and rotator cuff deficiency, reverse shoulder arthroplasty can provide improvement in function and decreased pain.Level of Evidence: Level IV, Case Series, Treatment Study

Results of surgical treatment for unstable distal clavicular fractures - Corrected Proof

2010-03-25

Hypothesis: Delayed surgical treatment of unstable distal clavicle fractures is associated with a higher complication rate.Materials and methods: Between 1998 and 2008, a retrospective study of 38 patients (average age, 42.9 year) with Neer type II clavicular fractures was performed. Fractures were treated with a hook-plate (22 patients) or with superior locked plate with suture augmentation (16 patients). Patients were divided into acute (27 patients) or delayed (11 patients) treatment groups based on the timing of surgical intervention before or after 4 weeks. All had clinical and radiographic follow-up for 1 year or until fracture union.Results: Union was achieved in 36 of 38 patients (94.7%). The acute treatment group had an average American Shoulder and Elbow Surgeons score of 77.9 compared with 65.0 in the delayed group. Six complications occurred (15.8%) including 2 infections (5.3%), 1 hardware failure (2.6%), and 3 peri-implant fractures (7.9%). The complication rate was 36.4% in the delayed group vs 7.4% in the acutely treated group (P = .047).Discussion: A high rate of union was observed in all cases regardless of timing or method of fixation. Despite a high rate of union, the results of treatment in the delayed group were more problematic. Patients treated with a hook-plate in a delayed fashion had more complications than those treated in an acute fashion (P = .039). Peri-implant fractures occurred only in patients treated with hook-plates.Conclusion: Surgical timing played a critical role in the outcome and complication rate in treatment of unstable distal third clavicle fractures.Level of evidence: Level III, Retrospective Cohort Comparison, Treatment Study

Diabetes mellitus impairs tendon-bone healing after rotator cuff repair - Corrected Proof

2010-03-22

Introduction: Studies have demonstrated a significant decrease in skeletal mass, bone mineral density, and impaired fracture healing in the diabetic population. However, the effect of sustained hyperglycemia on tendon-to-bone healing is unknown.Materials and methods: Forty-eight male, Lewis rats underwent unilateral detachment of the supraspinatus tendon followed by immediate anatomic repair with transosseous fixation. In the experimental group (n = 24), diabetes was induced preoperatively via intraperitoneal injection of streptozotocin (STZ, 65 mg/kg) and confirmed with both pre- and post-STZ injection intraperitoneal glucose tolerance tests (IPGTT). Animals were sacrificed at 1 and 2 weeks postoperatively for biomechanical, histomorphometric, and immunohistochemical analysis. Serum hemoglobin A1c (HbA1c) levels were measured at 2 weeks postoperatively. Statistical comparisons were performed using Student t tests with significance set at P < .05.Results: IPGTT analysis demonstrated a significant impairment of glycemic control in the diabetic compared to control animals (P < .05). Mean HbA1c level at 2 weeks postoperatively was 10.6 ± 2.7% and 6.0 ± 1.0% for the diabetic and control groups, respectively (P < .05). Diabetic animals demonstrated significantly less fibrocartilage and organized collagen, and increased AGE deposition at the tendon-bone interface (P < .05). The healing enthesis of diabetic animals demonstrated a significantly reduced ultimate load-to-failure (4.79 ± 1.33N vs 1.60 ± 1.67N and 13.63 ± 2.33N vs 6.0 ± 3.24N for control versus diabetic animals at 1 and 2 weeks, respectively) and stiffness compared to control animals (P < .05).Discussion: Sustained hyperglycemia impairs tendon-bone healing after rotator cuff repair in this rodent model. These findings have significant clinical implications for the expected outcomes of soft tissue repair or reconstructive procedures in diabetic patients with poor glycemic control.

Regarding “Optimizing stability in distal humeral fracture fixation” - Corrected Proof

Andrea Emilio Salvi — 2009-02-25

I have read with great interest the article by O'Driscoll concerning how to optimize stability in distal humeral fractures. In this article O'Driscoll illustrates in detail how to locate the screws along the distal humerus to accomplish at the same time maximum fixation of the bony fragments and restoration of articular geometry. I have carefully analyzed the figures of the article showing the technical objectives.

Regarding “Subacromial pain pump use with arthroscopic shoulder surgery: A short-term prospective study of complications in 583 patients“ - Corrected Proof

B.G.C.W. Pijls, L.L.A. Kleijn — 2009-02-23

We have read with great interest the article by Busfield et al, and we would like to congratulate them with their excellent results. To our knowledge, this is the only study that addresses short-term complications of subacromial pain pumps in a large patient group. The authors conclude that subacromial pain pump systems used for arthroscopic shoulder surgery are safe in the short term. Although this a valid conclusion from the presented data, we would like to shine a skeptical light on these results by briefly presenting a case of our own.