Journal of Shoulder and Elbow Surgery - Articles in Press

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

2012-01-30

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

The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy - Corrected Proof

2012-01-24

Background: Hemiarthroplasty (humeral head replacement [HHR]) and reverse shoulder arthroplasty (RSA) are surgical options for cuff tear arthropathy (CTA). RSA may provide better pain relief and functional outcomes, but it costs more and may have a higher complication rate. The goal of this study was to compare the cost-effectiveness of these two treatments and to use sensitivity analysis to determine the drivers of the model.Materials and methods: A Markov decision model was used. Outcome and complication probabilities were obtained from existing literature. Costs were based on average Medicare reimbursement and implant prices. Utilities were derived from responses to health state surveys (Short Form 6D) from 31 patients at one institution who underwent RSA or HHR for CTA. Incremental cost-effectiveness ratios were used to compare treatments.Results: Our model showed RSA could be a cost-effective strategy for treatment of CTA, using $100,000 per quality-adjusted life-year gained as a cutoff and the Short Form 6D for utilities. The model was extremely sensitive to the complication rate and the utility of each procedure and was also sensitive to implant price, with an implant price <$13,000 making RSA cost-effective.Conclusions: Currently available cost and outcome data show that RSA could be a cost-effective alternative to HHR for CTA. The cost-effectiveness of RSA depends most on the health utility gained from the operation, the utility lost due to complications from the operation, and the cost of the implant. Dropping the implant price to <$7,000 increases cost-effectiveness to <$50,000 per quality-adjusted life-year gained. Further head-to-head studies evaluating the clinical and quality of life outcomes of these two treatments are warranted.

Long-term follow-up of cases of rotator cuff tear treated conservatively - Corrected Proof

Hiroaki Kijima, Hiroshi Minagawa, Tomio Nishi, Kazuma Kikuchi, Yoichi Shimada — 2012-01-24

Background: This study clarified the long-term results of conservative treatment of rotator cuff tears.Materials and methods: This study focused on 103 shoulders diagnosed with rotator cuff tears by magnetic resonance imaging or arthrography at our institution from 1996 to 1999. Sixty-five shoulders were followed up by telephone survey and 43 of these shoulders were evaluated; 11 shoulders were excluded because the patient had died, 10 shoulders because of severe dementia, and 1 shoulder that had undergone trauma. The mean patient age for these 43 shoulders at the time of diagnosis was 62 years, and the mean follow-up period was 13 years. The pain score (30 points) and the activities-of-daily-life score (10 points) of the Japanese Orthopaedic Association shoulder scoring system were determined.Results: The mean pain score was 25.4 points, and the proportion of patients with no pain or with only slight pain was 88%. The mean score for activities of daily life was 9.4 points, and the proportion of patients with no disturbance in daily life was 72%. The patients with fewer than 20 points out of the possible 40 points (30 points for pain score plus 10 points for activities-of-daily-life score) were significantly younger than the other patients.Conclusions: In cases of rotator cuff tears treated conservatively, at 13 years after diagnosis, about 90% of patients had no or only slight pain and about 70% had no disturbance in activities of daily life. However, the younger patients tended to have more significant pain or disorder in daily life more than 10 years after diagnosis.

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

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

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

Effect of expectations and concerns in rotator cuff disorders and correlations with preoperative patient characteristics - Corrected Proof

Joo Han Oh, Jong Pil Yoon, Jae Yoon Kim, Sae Hoon Kim — 2012-01-24

Hypothesis: Expectations and concerns affect the patient's postoperative improvement after rotator cuff surgery and are associated with preoperative functional status and sociodemographic factors of the patients.Methods: We studied 128 patients who underwent rotator cuff surgery. Questionnaires regarding preoperative expectations and concerns were completed before surgery. The Simple Shoulder Test (SST), Constant-Murley score, and the Short Form 36-Item (SF-36) Health Survey were used to evaluate functional status.Results: The mean expectation score was 4.59 of 5. “Relief from symptoms” generated the highest level of expectations (4.78), and the mean concern score was 1.75 of 4. The length of recovery (2.31) was the most concerning issue. Postoperative functional outcomes were significantly improved in the high-expectation group as measured by the SST (P = .024) and the Constant-Murley score (P < .001). In contrast, patients with higher levels of concern showed no significant differences in the SST or the Constant-Murley score. High expectations were associated with occupation, level, and route of information about the disease, and poorer preoperative functional status. High concerns were associated with female sex and a poor mental health status on the SF-36.Conclusions: Patient expectations and concerns are related to postoperative improvements, and preoperative patient characteristics could be predictors of expectations (state of employment, higher level of information, informed by doctor, and a poorer preoperative functional status) and concerns (female and a poorer SF-36 Mental Component Summary score).

Effect of pretension and suture needle type on mechanical properties of acellular human dermis patches for rotator cuff repair - Corrected Proof

2012-01-24

Background: Dermal grafts are used for rotator cuff repair and augmentation. Although the in vitro biomechanical properties of dermal grafts have been reported previously, clinical questions related to their biomechanical performance as a surgical construct and the effect of surgical variables that could potentially improve repair outcomes have not been studied.Methods: This study evaluated the failure and fatigue biomechanics of acellular dermis constructs tested in a clinically relevant size (4 × 4 cm patches) and manner (loaded via sutures) for rotator cuff repair. Also investigated were the effect of 2 surgical variables: (1) the fixation of grafts under varying magnitudes of pretension (0, 10, 20N), and (2) the use of reverse-cutting vs tapered needles for suturing grafts.Results: Dermis constructs stretched ∼25% before bearing significant loads in the high stiffness region. Although 91% of the patches withstood 2500 cycles of loading to 150 N, the constructs stretched 13 to 19 mm after fatigue loading. This elongation could be reduced by 20% to 32% when reverse-cutting needles were used to prepare constructs or by applying 20 N of in situ circumferential pretension to the constructs before loading.Conclusions: Although dermis patches demonstrated robustness for use in rotator cuff repair, the patches underwent significant, substantial, and presumably nonrecoverable elongation, even at low physiologic loads. This study indicates that use of reverse-cutting needles for suture passage, preconditioning (cyclically stretching several times), and/or surgical fixation under at least 20 N of circumferential pretension could be developed as strategies to reduce compliance of dermis for its use for rotator cuff repair.

Operative guidelines for the reconstruction of the native glenoid plane: an anatomic three-dimensional computed tomography-scan reconstruction study - Corrected Proof

2012-01-24

Background: Reconstruction of the native plane in biconcave eroded glenoids is difficult. Nevertheless, accurate reconstruction of this plane is imperative for successful total shoulder arthroplasty. This study aims to determine guidelines that can increase the accuracy of glenoid component positioning.Methods: Three different circular planes were determined on 3-dimensional computed tomography (CT) scans of 152 healthy shoulders. First, the circular max (CM) plane is formed with the superior tubercle and 2 points, 1 anterior and 1 posterior, at the rim of the inferior third of the glenoid. Second, the circular inferior (CI) plane is formed by 3 points at the inferior 2 quadrants of the glenoid rim. Third, the circular minima (Cm) plane is formed with 3 points situated at the noneroded sector of the anterior glenoid.The angulation of the spinal scapular axis (SSA), the line between the most medial point of the scapular spine and the center of the three different glenoid planes, and the correlation coefficient between the radius of the circle and the length of SSA are calculated.Results: Angle SSA in the x-axis were 94°, 93°, 93° and in the y-axis were 95°, 111°, and 111° for CM, CI, and Cm, respectively. Correlation coefficient between the radius of the circle and the length of SSA: r = 0.69 for CM, r = 0.75 for CI, and r = 0.75 for Cm.Conclusion: Three points situated at the native anterior glenoid can reconstruct, within 2° accuracy (95% confidence interval, 1.8°-2.3°), the CI plane. A relationship exists between the radii of the 3 glenoid circles and the width of the scapula (SSA length).

Clavicle anatomy and the applicability of intramedullary midshaft fracture fixation - Corrected Proof

Abdo Bachoura, Andrew S. Deane, Srinath Kamineni — 2012-01-24

Background: This study investigated the morphologic safety and applicability of intramedullary fixation of midshaft clavicle fractures by analyzing the pertinent clavicle anatomy using 3-dimensional computer simulation.Materials and methods: Computed tomography was used to scan 22 skeletonized clavicles. Computer software was used to simulate middle-segment fracture fixation by fitting a cylindrical corridor within the clavicle in the area that intramedullary devices normally cross during surgery. The cylindrical corridor crossed the fracture line on both sides, and the number of cortical diameters that were bypassed was recorded. We assumed that 1 to 2 cortical diameters had to be bypassed to achieve adequate fixation. The medial and lateral exit points of the cylindrical corridor were measured and described in relation to the sternoclavicular and acromioclavicular ends respectively.Results: Simulation revealed that 15 of 22 clavicles could be bypassed by 2 cortical diameters on either side of the midline fracture, 6 clavicles could be bypassed by 1 cortical diameter medial to the fracture line, and 1 clavicle could not be bypassed by any cortical diameters medial to the fracture line. The medial exit point of the cylindrical corridor was anterior in 20 of 22 cases and an average of 44.2 mm lateral to the sternoclavicular end. The lateral exit point of the cylindrical corridor was posterosuperior in 16 of 22 cases and an average of 26.5 mm medial to the acromioclavicular end.Conclusion: In most clavicles, straight intramedullary fixation appears to be a morphologically safe and effective method of fixation.

The outcome of manipulation under general anesthesia for the management of frozen shoulder in patients with diabetes mellitus - Corrected Proof

2012-01-24

Hypothesis: Frozen shoulder has a greater incidence, more severe course, and resistance to treatment in patients with diabetes mellitus compared with the general population. We hypothesized that diabetic patients with frozen shoulder undergoing treatment with manipulation under general anaesthesia (MUA) would have the same outcome as patients without diabetes.Materials and methods: We retrospectively analyzed data collected during a 10-year period of referrals for frozen shoulder. In all cases, a standardized MUA protocol was followed once the diagnosis of frozen shoulder in the frozen phase was made; this included an early repeat MUA in individuals with recurrence. We compared outcomes for patients documented as having diabetes with a nondiabetic control group and assessed the effect of insulin dependence and frozen shoulder etiology within the diabetic group.Results: Of a consecutive series of 315 frozen shoulders, 36 patients (39 shoulders) were included in the diabetic group, with 256 patients (274 shoulders) as controls. There was a significant improvement in range of movement and Oxford Shoulder Score (P all <.001), with no difference between diabetic and control groups at early or late follow-up (mean, 41 months). A repeat procedure was required in 36% of diabetic patients compared with 15% of control patients. Recurrence in the diabetic group was influenced by etiology (47% of primary vs 0% of secondary frozen shoulders) and insulin requirement (39% insulin-dependent vs. 31% non–insulin-dependent).Conclusion: We provide a strategy for the management of diabetic frozen shoulders using MUA and estimates of success and recurrence rates that may be useful when informing consent.

Current concepts review: revision rotator cuff repair - Corrected Proof

Michael S. George, Michael Khazzam — 2012-01-09

Failed rotator cuff repair may be caused by surgical complications, diagnostic errors, technical errors, failure to heal, and traumatic failure. Revision rotator cuff repair is made technically more difficult by poor tissue quality, tissue adhesions, and retained suture and suture anchor material. Historically, open revision rotator cuff repair yields inferior results compared with primary rotator cuff repair; however, more recent studies show 52% to 69% satisfactory results in small-sized or medium-sized tears. Arthroscopic revision rotator cuff repair yields greater than 60% good or excellent results. Poor tissue quality, detachment of the deltoid origin, and multiple previous surgeries are risk factors for poor results in revision rotator cuff repair.

Erratum to “Arthroscopic tissue biopsy for evaluation of infection before revision arthroplasty” [J Shoulder Elbow Surg 2011;20:e15-e22] - Corrected Proof

Monica Morman, Rachel L. Fowler, Ben Sanofsky, Laurence D. Higgins — 2012-01-09

In the abovementioned article, the third author’s name was spelled incorrectly. The correct spelling of the author’s name is Ben Sanofsky. We sincerely apologize for this error.

Treatment strategies for periprosthetic infections after primary elbow arthroplasty - Corrected Proof

2012-01-06

Background: The goal of this study was to investigate the outcome of different surgical procedures (debridement and retention vs 1- or 2-stage exchange) together with a well-defined antimicrobial regimen.Materials and methods: A total of 236 consecutive patients underwent 262 primary elbow arthroplasties between January 1994 and December 2007. We observed 20 episodes of periprosthetic infections in 19 patients and placed them into 3 groups according to the occurrence of infection after index surgery. A total of 9 early infections (<3 months), 1 delayed infection (3-24 months), and 10 late infections (>24 months) were observed. The treatment among those 3 groups was compared, and the outcome was assessed with a mean follow-up of 60.2 months.Results: In the group with early infections (n = 9), 8 cases were treated by irrigation and debridement and 1 case was treated by a 2-stage exchange without recurrence of infection. The mean Mayo Elbow Performance Score improved from 48.3 points (range, 30-75 points) to 91.7 points (range, 85-100 points). The delayed infection was treated by 1-stage exchange without recurrence of infection. For late infections (n = 10), 3 cases presented recurrence of infection after debridement and irrigation, and the mean Mayo Elbow Performance Score remained nearly unchanged, from 60 points (range, 45-80 points) to 65 points (range, 50-80 points). Eradication of infection could be achieved by staged revision and in 3 cases by debridement.Conclusion: Both debridement with retention and staged reimplantation are highly successful for appropriate indications. Staged revisions are successful even against biofilm-active microorganisms, but a prosthesis-free interval of at least 3 months is recommended.

Relationship of radiographic acromial characteristics and rotator cuff disease: a prospective investigation of clinical, radiographic, and sonographic findings - Corrected Proof

2012-01-05

Background: Many studies have attempted to correlate radiographic acromial characteristics with rotator cuff tears, but the results have not been conclusive. Therefore, the purpose of this study was to determine the relationship between rotator cuff disease and the development of symptoms with different radiographic acromial characteristics, including shape, index, and presence of a spur.Materials and methods: The records of 216 patients enrolled in an ongoing prospective, longitudinal study investigating asymptomatic rotator cuff tears were reviewed. All patients underwent standardized radiographic evaluation, clinical evaluation, and shoulder ultrasonography at regularly scheduled surveillance visits. Three blinded observers reviewed all radiographs to determine the acromial morphology, presence, and size of an acromial spur, as well as the acromial index. These findings were analyzed to determine an association with the presence of a full-thickness rotator cuff tear.Results: The 3 observers demonstrated poor agreement for acromial morphology (κ = 0.41), substantial agreement for the presence of an acromial spur (κ = 0.65), and excellent agreement for the acromial index (κ = 0.86). The presence of an acromial spur was highly associated with the presence of a full-thickness rotator cuff tear (P = .003), even after adjusting for age. No association was found between the acromial index and rotator cuff disease (P = .92).Conclusion: The presence of an acromial spur is highly associated with the presence of a full-thickness rotator cuff tear in symptomatic and asymptomatic patients. The acromial morphology classification system is an unreliable method to assess the acromion. The acromial index shows no association with the presence of rotator cuff disease.

Shoulder internal rotation elbow flexion test for diagnosing cubital tunnel syndrome - Corrected Proof

2012-01-05

Background: Shoulder internal rotation enhances symptom provocation attributed to cubital tunnel syndrome. We present a modified elbow flexion test—the shoulder internal rotation elbow flexion test—for diagnosing cubital tunnel syndrome.Methods: Fifty-five ulnar nerves in cubital tunnel syndrome patients and 123 ulnar nerves in controls were examined with 5 seconds each of elbow flexion, shoulder internal rotation, and shoulder internal rotation elbow flexion tests before and after treatment (surgery in 18; conservative in others). For the shoulder internal rotation elbow flexion test position, 90° abduction, maximum internal rotation, and 10° flexion of the shoulder were combined with the elbow flexion test position. The test was considered positive if any symptom for cubital tunnel syndrome developed <5 seconds. Influence of the shoulder internal rotation elbow flexion test was evaluated by nerve conduction studies in 10 cubital tunnel syndrome nerves and 7 control nerves.Results: The sensitivities/specificities of the 5-second elbow flexion, shoulder internal rotation, and shoulder internal rotation elbow flexion tests were 25%/100%, 58%/100%, and 87%/98%, respectively. Sensitivity differences between the shoulder internal rotation elbow flexion test and the other two tests were significant. Shoulder internal rotation elbow flexion test results and cubital tunnel syndrome symptoms were significantly correlated. Influence of the shoulder internal rotation elbow flexion test on the ulnar nerve was seen in 8 of 10 cubital tunnel syndrome nerves but not in controls.Conclusions: The 5-second shoulder internal rotation elbow flexion test is specific, easy and quick provocative test for diagnosing cubital tunnel syndrome.

Muscle releases to improve passive motion and relieve pain in patients with spastic hemiplegia and elbow flexion contractures - Corrected Proof

Surena Namdari, J. Gabe Horneff, Keith Baldwin, Mary Ann Keenan — 2012-01-04

Introduction: Patients with spastic hemiplegia after upper motor neuron (UMN) injury can develop elbow contractures. This study evaluated outcomes of elbow releases in treating spastic elbow flexion contractures in hemiplegic patients.Methods: Adults with spastic hemiplegia due to UMN injury who underwent elbow releases (brachialis, brachioradialis, and biceps muscles) were included. Nonoperative treatment was unsuccessful in all patients. Patients complained of difficulty with passive functions. Passive range of motion (ROM), pain relief, Modified Ashworth spasticity score, and complications were evaluated preoperatively and postoperatively.Results: There were 8 men and 21 women with an average age of 52.4 years (range, 24.1-81.4 years). Seventeen patients had pain preoperatively. Postoperative follow-up was a mean of 1.7 years (range, 1-4.5 years). Preoperatively, patients lacked a mean of 78° of passive elbow extension compared with 17° postoperatively (P < .001). The Modified Ashworth spasticity score improved from 3.3 to 1.4 (P = .001). All patients with preoperative pain had improved pain relief, and 16 (94%) were pain-free. There were 3 wound complications that resolved nonsurgically and 1 recurrence. Age, sex, etiology, and chronicity of UMN injury were not associated with improvement in motion or pain relief (P > .05).Conclusion: Releases of the brachialis, brachioradialis, and biceps muscles can be an effective means of pain relief, improved passive ROM, and decreased spasticity in patients with elbow flexion deformity after UMN injury.

Chronic incarceration of the medial epicondyle: a case report - Corrected Proof

2012-01-04

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

Improved strength of early versus late supraspinatus tendon repair: a study in the rabbit - Corrected Proof

Guy Trudel, Nanthan Ramachandran, Stephen E. Ryan, Kawan Rakhra, Hans K. Uhthoff — 2012-01-04

Hypothesis: The optimal timing for surgical repair of the supraspinatus (SSP) tendon after full-substance tear has not been established. The objectives of this prospective investigation of SSP tendon repair delayed by 1, 2, or 3 months followed by a 3-month postoperative course were to (1) determine the site of failure, (2) measure the tensile strength and stiffness, and (3) assess the ability of computed tomography to predict mechanical strength.Materials and Methods: We transected 1 SSP tendon in 36 rabbits and then repaired it with transosseous sutures after a delay of 1, 2, or 3 months. We compared the results with 36 intact shoulders from 18 age-matched control rabbits.Results: Experimental specimens failed at the tendon (n = 26) more often than at the enthesis (n = 10) (P < .05). The mean peak loads to failure 3 months after repair delayed by 1 month and delayed by 2 months were significantly greater than their respective control values (P < .05 for both); there was no difference after a delay of 3 months. There was no association between the presence of hypoattenuation on computed tomography and repair strength (P > .05).Conclusions: Our findings indicate better mechanical results with earlier repair (1 or 2 months) after SSP tendon than after a delay of 3 months. Early surgical repair may lower the risk of tendon retear.

Prediction of coracoid thickness using a glenoid width–based model: implications for bone reconstruction procedures in chronic anterior shoulder instability - Corrected Proof

Karin L. Ljungquist, R. Bryan Butler, Michael J. Griesser, Julie Y. Bishop — 2012-01-04

Background: Chronic anterior shoulder instability with glenoid bone loss can be a very challenging clinical problem. Significant bone loss is commonly managed with the Latarjet procedure. However, in some cases with severe glenoid bone loss, iliac crest bone grafting is required to obtain a graft of adequate size. Iliac crest bone graft is associated with high rates of donor-site complications. Whereas glenoid dimensions can be determined by use of 3-dimensional computed tomography reconstructions, the thickness of the coracoid cannot be easily measured. This study aims to define a ratio between glenoid width and coracoid thickness that can be used in preoperative planning to determine whether coracoid transfer will yield adequate bone graft to restore glenoid contour or whether iliac crest bone graft must be taken.Methods: We studied 100 paired cadaveric scapulae (50 male and 50 female scapulae). The bony dimensions of the coracoid and glenoid were measured for each specimen.Results: Coracoid and glenoid dimensions are provided. The mean thickness of the male coracoid was 35.4% of the width of the glenoid. The mean female coracoid thickness was 34.4% of the glenoid width.Discussion: A new biomorphologic model is presented to predict coracoid thickness and the ability of the Latarjet procedure to restore stability to a given bone-deficient glenoid. This model may aid the shoulder surgeon in preoperative planning and help promote successful outcomes in glenoid reconstruction surgery by determining whether a Latarjet procedure or iliac crest bone graft is the most appropriate procedure given the predicted amount of coracoid bone graft available.

Acute traumatic brachialis rupture in a young rugby player: a case report - Corrected Proof

Karthik S. Murugappan, Khalid Mohammed — 2012-01-04

Acute tear of brachialis muscle is rare and has been infrequently reported. We present a case of acute rupture of the brachialis muscle in a young rugby player. A brief review of literature is also presented.

Operative treatment of isolated teres major ruptures - Corrected Proof

Grant E. Garrigues, Mark D. Lazarus — 2012-01-04

Complete rupture of the teres major is an extremely rare injury. The role of the teres major in upper extremity function is debatable, and all known cases have been treated nonoperatively with good results. However, the only study to measure strength objectively noted deficits after nonoperative treatment. Here we report the short-term results of the first case of a teres major rupture treated operatively. Our results were not improved over historical, nonoperative controls, and we do not recommend operative treatment for this injury.

In vivo temperature measurement in the subacromial bursa during arthroscopic subacromial decompression - Corrected Proof

Scott L. Barker, Alan J. Johnstone, Kapil Kumar — 2011-12-26

Background: The purpose of the study was to evaluate whether use of a bi-polar radiofrequency (RF) ablation wand would cause excess heating, which may lead to collateral damage to the surrounding tissues during arthroscopic subacromial decompression. Cadaveric studies have shown that high temperatures can potentially be reached when using RF ablation wands in arthroscopic shoulder surgery. Only 1 other published study assesses these temperature rises in the clinical setting.Methods: Fifteen patients were recruited to participate in the study. A standard arthroscopic subacromial decompression was performed using continuous flow irrigation, with intermittent use of the RF ablation wand for soft tissue debridement. The temperature of the irrigation fluid within the subacromial bursa and the outflow fluid from the suction port of the wand were measured during the procedure using fiber-optic thermometers.Results: The mean peak temperature recorded in the subacromial bursa was 32.0°C (29.3-43.1°C), with a mean rise from baseline of 9.8°C. The mean peak temperature recorded from the outflow fluid from the wand was 71.6°C (65.6-77.6°C), with a mean rise from baseline of 49.4°C.Conclusion: High temperatures were noted in the outflow fluid from the wand; however, this was not evident in the subacromial bursa itself. Use of room temperature inflow fluid, maintenance of flow through the bursa, and avoidance of prolonged uninterrupted use of the wand all appear to ensure that safe temperatures are maintained in the subacromial bursa not only in the laboratory but also in a clinical setting.

Validation of the Dutch version of the Simple Shoulder Test - Corrected Proof

2011-12-26

Background: The Simple Shoulder Test (SST) is an internationally used patient-reported outcome for clinical practice and research purposes. It was developed for measuring functional limitations of the affected shoulder in patients with shoulder dysfunction and contains 12 questions (yes/no). The purpose of this study was to create a Dutch translation of the SST and to assess the reliability and validity.Materials and methods: The SST was translated into Dutch using forward and backward translations. A consecutive cohort of patients with shoulder problems visiting an orthopedic clinic completed the Dutch version of the SST twice within 28 days. In addition, the Dutch validated versions of the Disabilities of the Arm, Shoulder and Hand, Oxford Shoulder Score, and Constant-Murley shoulder assessment were completed for assessing construct validity.Results: One hundred ten patients with a mean age of 39 years (SD, 14 years), 72% male, completed the questionnaires. The internal consistency was high (Cronbach α, 0.78). The test-retest reliability was very good (intraclass correlation coefficient, 0.92) (n = 55). The measurement error expressed in the standard error of measurement was 1.18, and the smallest detectable change was 3.3 on a scale from 0 to 12. The construct validity was supported by expected high correlations between the Dutch version of the SST and the Disabilities of the Arm, Shoulder and Hand (r = −0.74) and between the SST and the Oxford Shoulder Score (r = −0.74) and an expected moderate correlation between the SST and the Constant-Murley shoulder assessment (r = 0.59).Conclusion: The Dutch version of the SST seems to be a reliable and valid instrument for evaluating functional limitations in patients with shoulder complaints.

Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction–internal fixation of proximal humeral fractures - Corrected Proof

2011-12-23

Background: We sought to examine fracture settling and screw penetration after open reduction–internal fixation of 2-, 3-, and 4-part proximal humeral fractures and determine whether the use of calcium phosphate cement reduced these unwanted complications.Methods: We performed a retrospective study of prospective data. Inclusion criteria included patient age of 18 years or older and an acute traumatic fracture of the proximal humerus that was treated with open reduction–internal fixation with a locked plate. Metaphyseal defects were treated with 1 of 3 strategies: no augmentation, augmentation with cancellous chips, or augmentation with calcium phosphate cement. Various radiographic measurements were made at each follow-up visit to assess for humeral head settling or collapse. Overall, 92 patients (81%) met the inclusion criteria and form the basis of this study. Augmentation type included 29 patients (32%) with cancellous chips, 27 (29%) with calcium phosphate cement, and 36 (39%) with no augmentation.Results: There were no statistical differences among the groups with respect to patient age, sex, and fracture type. At the 3, 6, and 12-month follow-up visits, there was less humeral head settling with calcium phosphate cement compared with repair with no augmentation or with cancellous chips. Findings of joint penetration were significant among patients treated with plates and screws alone versus those augmented with calcium phosphate (P = .02) and for those augmented with cancellous chips versus those augmented with calcium phosphate (P = .009).Conclusion: Augmentation with calcium phosphate cement in the treatment of proximal humeral fractures with locked plates decreased fracture settling and significantly decreased intra-articular screw penetration.

Postoperative acromion base fracture resulting in subsequent instability of reverse shoulder replacement - Corrected Proof

Jonathan C. Levy, Sara Blum — 2011-12-23

Postoperative acromion fractures have been reported to occur in 3% to 7% of patients treated with reverse shoulder replacement. Although many acromion fractures heal uneventfully, worse outcomes have been reported for fractures that occur where the acromion base attaches to the scapular spine. In these fractures, the entire acromion is pulled inferiorly, resulting in a change in the radiographic appearance of the shoulder. Because at least two-thirds of the deltoid origin is attached to the acromion and scapular spine, the inferior tilt of the acromion that occurs with these postoperative fractures can result in a loss of deltoid tension. We report a postoperative acromion base fracture in a patient that subsequently resulted in instability and dislocation of a reverse shoulder arthroplasty.

Postoperative pain associated with orthopedic shoulder and elbow surgery: a prospective study - Corrected Proof

Vimal N. Desai, Emilie V. Cheung — 2011-12-23

Background: In the last 2 decades, extensive research in postoperative pain management has been undertaken to decrease morbidity. Orthopedic procedures tend to have increased pain compared with other procedures, but further research must be done to manage pain more efficiently. Postoperative pain morbidities and analgesic dependence continue to adversely affect health care.Materials and methods: The study assessed the pain of 78 elbow and shoulder surgery patients preoperatively and postoperatively using the Short-Form McGill Pain Questionnaire (SF-MPQ). Preoperatively, each patient scored their preoperative pain (PP) and anticipated postoperative pain (APP). Postoperatively, they scored their 3-day (3dpp) and 6-week postoperative pain (6wpp). The pain intensities at these 4 intervals were then compared and analyzed using Pearson coefficients.Results: APP and PP were strong predictors of postoperative pain. The average APP was higher than the average postoperative pain. The 6wpp was significantly lower than the 3dpp. Sex, chronicity, and type of surgery were not significant factors; however, the group aged 18 to 39 years had a significant correlation with postoperative pain.Conclusion: PP and APP were both independent predictors of increased postoperative pain. PP was also predictive of APP. Although, overall postoperative pain was lower than APP or PP due to pain management techniques, postoperative pain was still significantly higher in patients with increased APP or PP than their counterparts. Therefore, surgeons should factor patient’s APP and PP to better manage their patient’s postoperative pain to decrease comorbidities.

Subscapularis function after transosseous repair in shoulder arthroplasty: transosseous subscapularis repair in shoulder arthroplasty - Corrected Proof

2011-12-23

Background: Postoperative subscapularis function has been identified as an essential factor influencing the outcome of shoulder arthroplasty. The goal of this study was an evaluation of subjective and objective subscapularis function after transosseous refixation.Methods: Twenty-three patients with an average age of 71 years (range, 51-86) and follow-up of 43 months (range, 24-67) were included in this study. The subscapularis was tenotomized from the lesser tuberosity and refixation was performed in a transosseous technique through bone tunnels with nonabsorbable sutures. Subscapularis function was evaluated subjectively by the ability to tuck a shirt and objectively with the lift-off test and strength measurement in internal rotation. Radiological assessment included ultrasound evaluation of the subscapularis and an axillary x-ray.Results: No complete, but 7 partial subscapularis tears were found on ultrasound (30.4%). Five patients were not able to tuck their shirt postoperatively (22.7%). This was associated with an inferior clinical outcome (American Shoulder and Elbow Surgeons [ASES] score 53.3 vs 76.4; P = .023). The lift-off test was positive in 4 patients (17.4%), which was also associated with an inferior clinical result (Constant score 52.3% vs 74.2%; P = .021). Nineteen patients were able to go through an internal rotation strength testing in the lift-off position, and averaged 3.8 kg.Conclusion: Although overall reliable refixation of the subscapularis was achieved by transosseous repair, almost 25% of patients showed signs of decreased function and 30% showed signs of partial defects. Subjective and objective functional deficits had a significant influence on the clinical outcome.

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

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

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

Delayed, transient musculocutaneous nerve palsy after the Latarjet procedure - Corrected Proof

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

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

Anterior shoulder pain due to persistence of a septum between long head biceps tendon and intra-articular supraspinatus - Corrected Proof

2011-12-19

Few embryologic anomalies of the long head of the biceps (LHB) tendon have been described in the literature, among which are absence of the LHB, bifurcate origin of the tendon, a split LHB tendon in a single origin from supraglenoid tubercle, and an intra-capsular or extra-capsular origin of this structure. Arthroscopy is a helpful tool to address these anatomic shoulder variants, and arthroscopic surgeons should recognize all varieties of the shoulder’s intra-articular structures. The study of morphologic development in this area is the one method that allows surgeons to improve their clinical knowledge, possibly yielding better results for their patients.

Finite element analysis and physiologic testing of a novel, inset glenoid fixation technique - Corrected Proof

2011-12-15

Hypothesis: The success of shoulder arthroplasty surgery has been limited by a common complication: glenoid implant loosening. Eccentric loading of the glenoid due to migration of the humeral head is considered to be the major cause of glenoid loosening and is referred to as the rocking-horse phenomenon. Glenoid implant loosening may cause pain, limitation of function, and the need for complicated revision surgery. Our hypothesis was that an inset fixation technique could offer increased fixation strength and minimize the effects of the rocking-horse phenomenon on glenoid loosening.Materials and methods: Fixation strength and stress distribution were analyzed using two methods. First, mechanical simulation of physiologic in vivo cyclic loading was performed on 1 inset glenoid implant design and 2 standard onlay glenoid implant designs currently on the market. Second, 3-dimensional finite element analysis was performed to compare an inset glenoid implant and a standard onlay glenoid implant with a keel and a standard onlay pegged implant.Results: After cyclic loading to 100,000 cycles, no glenoid implants demonstrated signs of loosening. Mechanical testing after cyclic loading demonstrated less distraction of the glenoid rim using an inset technique compared with an onlay technique. Finite element analysis results indicated that the inset technique achieved up to an 87% reduction in displacement.Conclusions: Mechanical tests and finite element analysis support the concept of inset glenoid fixation in minimizing the risk of glenoid loosening.

Acute brachialis muscle rupture caused by closed elbow dislocation in a professional American football player - Corrected Proof

2011-12-15

Injury to the brachialis muscle is rare, with only several patients with isolated injury reported. The brachialis muscle is anatomically close to the anterior capsule and the joint of the elbow, placing the muscle at risk during elbow dislocation; however, this has never been described. In contrast, elbow dislocations have an incidence of approximately 6 per 100,000, making them the second most frequent dislocations encountered after shoulder dislocations. Most elbow dislocations affect young adults, often involved in a sports injury. In most individuals, these injuries involve only the joint and carry a good prognosis after reduction, brief immobilization, and active rehabilitation. Most of the current studies emphasize the indications and outcomes of repairing the ligaments or in restoring motion of the elbow joint. We report a brachialis muscle rupture associated with closed elbow dislocation and the results of surgical repair in a high-demand professional athlete.

Recovery of sensory disturbance after arthroscopic decompression of the suprascapular nerve - Corrected Proof

Naomi Oizumi, Naoki Suenaga, Tadanao Funakoshi, Hiroshi Yamaguchi, Akio Minami — 2011-12-12

Background: The existence of sensory branches of the suprascapular nerve (SSN) has recently been reported, and sensory disturbance at the lateral and posterior aspect of the shoulder has been focused on as a symptom of SSN palsy. We have performed arthroscopic release of SSN at the suprascapular notch in patients with sensory disturbance since 2006. The purposes of this study were to introduce the arthroscopic surgical technique and investigate postoperative recovery of sensory disturbance.Materials and methods: The study included 11 men and 14 women (25 shoulders), with an average age of 63.9 years (range, 41-77 years). Arthroscopic decompression of the SSN was performed using a suprascapular nerve (SN) portal as a landmark for approaching the suprascapular notch. Sensory disturbance of the shoulder was evaluated preoperatively and postoperatively. The average follow-up was 18.5 months (range, 12-30 months).Results: The arthroscopic procedures were performed safely. The preoperative sensory disturbance fully recovered postoperatively in all shoulders.Conclusion: Arthroscopic release of the SSN is a useful procedure for SSN entrapment at the suprascapular notch. The sensory disturbance at the lateral and posterior aspect of the shoulder can be used as one of the criteria of diagnosing SSN palsy, especially in shoulders with massive rotator cuff tear, in which diagnosing and assessing the treatment results of associated SSN palsy is usually difficult.

Surgical management of uncomplicated midshaft clavicle fractures: A comparison between titanium elastic nails and small reconstruction plates - Corrected Proof

Yih-Wen Tarng, Shan-Wei Yang, Yen-Po Fang, Chien-Jen Hsu — 2011-12-12

Background: This study compared titanium elastic nail (TEN) fixation with plate fixation in patients with uncomplicated midshaft clavicle fractures.Methods: The records of 57 patients with midshaft clavicular fractures that were operated on within 2 weeks after injury at Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan, were retrospectively analyzed. Each patient received either TENs (n = 25) or fixation with a 3.5-mm reconstruction plate (n = 32) depending on the preference of the operating surgeon. Operative parameters, postoperative pain and function scores, complications, and fracture union time were determined.Results: There was no difference in the fracture pattern distribution between the 2 groups, and all operations were performed without complications. Operation time, wound size, blood loss, length of hospitalization, and subjective time to pain relief were less for the TEN group than for the 3.5-mm reconstruction plate fixation group (P < .001 for all). Patients in the TEN group showed a greater range of shoulder motion and higher Constant scores than those in the plate fixation group up to 18 weeks after surgery (P < .001 for all). Fewer patients in the TEN group, 4 (16%), requested removal of the implant, as compared with 12 (37.5%) in the plate group.Conclusion: Fixation of uncomplicated midshaft clavicle fractures with TENs provides adequate fixation and faster relief of pain and return to normal function of the affected shoulder than fixation with 3.5-mm reconstruction plates.

Pattern and time phase of shoulder function and power recovery after arthroscopic rotator cuff repair - Corrected Proof

2011-12-12

Background: It has been our observation that early during rehabilitation after rotator cuff repair, patients may take a step back before improving. The purpose of this study is to investigate the pattern and time phase of changes in Constant score and strength recovery after arthroscopic rotator cuff repair.Materials and Methods: Forty-five patients undergoing arthroscopic rotator cuff repair were prospectively enrolled in this study. Patients underwent scoring preoperatively with the Constant score. All were followed up at 3 months and 6 months after surgery. The Constant score and strength at 3 months were compared with those at the 6-month mark.Results: The mean Constant score improved from 46.4 points (SD, 17.3) preoperatively to 51.8 points (SD, 13.5) 3 months postoperatively (P = .0777). At 6 months postoperatively, the mean Constant score was 69.0 points (SD, 11.1), a significant increase from both the preoperative (P < .0001) and 3-month (P < .0001) results. The mean preoperative strength result of 4.5 kg (SD, 3.2) decreased significantly to 3.3 kg (SD, 1.8) at 3 months postoperatively (P = .0154) before improving to 5.8 kg (SD, 2.6) at 6 months postoperatively. The improvement in strength at 6 months was significant compared with both the preoperative (P = .0070) and 3-month (P < .0001) results.Conclusions: Although there is highly significant improvement in overall function (Constant score) and strength 6 months postoperatively, patients appear to take a step back before improving, in fact with a drop in strength at 3 months. This may cause concern in patients and may require assurance that time and effort with physiotherapy will improve function and symptoms.

Periprosthetic infections after shoulder hemiarthroplasty - Corrected Proof

2011-12-12

Background: To examine the rates and predictors of deep periprosthetic infections after shoulder hemiarthroplasty.Methods: We used prospectively collected institutional registry data on all primary shoulder hemiarthroplasty patients from 1976-2008. We estimated survival free of deep periprosthetic infections using Kaplan-Meier survival curves. Using univariate Cox regression analyses, we examined the association of patient-related factors (age, sex, body mass index), comorbidity (Deyo-Charlson index), American Society of Anesthesiologists grade, underlying diagnosis, and implant fixation with the risk of infection.Results: A total of 1,349 patients, with a mean age of 63 years (SD, 16 years), 63% of whom were women, underwent 1,431 primary shoulder hemiarthroplasties. Mean follow-up was 8 years (SD, 7 years). Fourteen deep periprosthetic infections occurred during the follow-up, confirmed by medical record review. The most common organisms were Staphylococcus aureus, coagulase-negative Staphylococcus, and Propionibacterium acnes, each accounting for 3 cases (21% each). The 5-, 10-, and 20-year prosthetic infection–free rates were 98.9% (95% confidence interval [CI], 98.3%-99.5%), 98.7% (95% CI, 98.1%-99.4%), and 98.7% (95% CI, 98.1%-99.4%), respectively. None of the factors evaluated were significantly associated with risk of prosthetic infection after primary shoulder hemiarthroplasty, except that an underlying diagnosis of trauma was associated with a significantly higher hazard ratio of 3.18 (95% CI, 1.06-9.56) for infection compared with all other diagnoses (P = .04). A higher body mass index showed a non–statistically significant trend toward an association with higher hazard (P = .13).Conclusion: The periprosthetic infection rate after shoulder hemiarthroplasty was low, estimated at 1.3% at 20-year follow-up. An underlying diagnosis of trauma was associated with a higher risk of periprosthetic infection. These patients should be observed closely for development of infection.

A biomechanical comparison of multidirectional nail and locking plate fixation in unstable olecranon fractures - Corrected Proof

Evan Argintar, Benjamin D. Martin, Andrea Singer, Adam H. Hsieh, Scott Edwards — 2011-12-12

Background: The main theoretic advantage of proximal olecranon fracture intramedullary fixation is decreased soft-tissue irritation and, potentially, less subsequent hardware removal. Despite this possible benefit, questions remain as to whether intramedullary devices are capable of controlling olecranon fractures to the same extent as locking plates. This study evaluates the ability of a novel multidirectional locking nail to stabilize comminuted fractures and directly compares its biomechanical performance with that of locking olecranon plates.Materials and methods: We implanted 8 stainless steel locking plates and stainless steel intramedullary nails to stabilize a simulated comminuted fracture in 16 fresh-frozen cadaveric elbows. Flexion-extension, varus-valgus, gap distance, and rotational 3-dimensional angular displacement analysis was conducted over a 60° motion arc (30° to 90°) to assess fragment motion through physiologic cyclic arcs of motion and failure loading. Displacements in all planes were compared.Results: Both implants showed less than 1° of motion in all measured planes and allowed less than 1 mm of gapping through all loads tested until ultimate failure. All failures occurred by sudden, catastrophic means. The mean failure weight for the nail was 14.4 kg compared with 8.7 kg for the plate (P = .02). The nail survived 1102 cycles, whereas the plate survived 831 cycles (P = .06).Conclusion: In simulated comminuted olecranon fractures, the multidirectional locking intramedullary nails sustained significantly higher maximum loads than the locking plates. The two implants showed no significant differences in fragment control or number of cycles survived. Surgeons can expect the multidirectional locking nails to stabilize comminuted fractures at least as well as locking plates.

A vascularized scapular graft for juvenile osteonecrosis of the humeral head - Corrected Proof

Kazuya Inoue, Naoki Suenaga, Naomi Oizumi, Yasuhito Tanaka, Akio Minami — 2011-12-12

Osteonecrosis of the humeral head is comparatively rare and occurs in less than 10% of patients with multiple osteonecrosis. The average age of onset is reported to be 40 to 50 years. Juvenile osteonecrosis is even rarer still. In addition, multiple osteonecrosis occurs in less than 5% of all patients who receive systemic steroid medication. Therefore, when a patient complains of shoulder pain and has a history of steroid treatment, osteonecrosis must be always kept in mind. Subjective symptoms usually start 6 to 18 months after commencement of steroid therapy. We present here a rare case of juvenile bilateral osteonecrosis of the humeral head after steroid treatment for acute lymphocytic leukemia. Osteonecrosis of the left humeral head was treated with vascularized scapular grafting, and the right humeral head, which had already shown collapse, was treated by humeral head replacement.

Open debridement and radiocapitellar replacement in primary and post-traumatic arthritis of the elbow: a multicenter study - Corrected Proof

2011-12-12

Background: Postmortem and clinical studies have shown an early and prevalent involvement of the radiohumeral joint in primary and secondary arthritis of the elbow. The lateral resurfacing elbow (LRE) prosthesis has recently been developed for the treatment of lateral elbow arthritis. However, few data have been published on LRE results.Materials and methods: A prospective multicenter study was designed to assess LRE preliminary results. There were 20 patients (average age, 55 years). Preoperative diagnosis were primary osteoarthritis in 11 and post-traumatic osteoarthritis in 9. All patients underwent open debridement and LRE prosthesis. Patients were evaluated preoperatively and postoperatively with the Mayo Elbow Performance Score (MEPS), modified American Shoulder Elbow Surgeons (m-ASES) elbow assessment, and the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH). Mean follow-up was 22.6 months.Results: At the last follow-up, the mean improvement of MEPS and m-ASES was 35 (P = .001) and 34 (P = .001) respectively; the average Quick DASH decreased by 29 (P = .001). Average range of motion was improved by 35° (P = .001). MEPI results were excellent in 12 patients, good in 2, and fair and poor in 3 each. Mild overstuffing was observed in 5 patients, and an implant malpositioning in 3. The implant survival rate was 100%.Conclusion: LRE showed promising results in this prospective investigation. Most patients had an uneventful postoperative course and have shown a painless elbow joint, with satisfactory functional recovery at short-term follow-up. Further studies with longer follow-up are warranted.

Antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders - Corrected Proof

2011-12-12

Background: Deep infection after primary reverse total shoulder arthroplasty is a devastating event and has an increased incidence compared with anatomic total shoulder arthroplasty. Recent reports in the hip and knee arthroplasty literature suggest that antibiotic-loaded bone cement may lower infection rates for primary arthroplasties. We conducted a retrospective cohort study to evaluate the effect of antibiotic-loaded bone cement vs plain bone cement on the prevention of deep infection after primary reverse total shoulder arthroplasty.Materials and methods: Four surgeons from their respective facilities participated in the retrospective cohort data collection. From 1999 to 2008, 501 consecutive primary reverse total shoulder arthroplasties were performed. Patients with revision of failed previous arthroplasties were excluded, and patients with any other previous shoulder procedure were included. Two groups were examined in this retrospective cohort: In group 1 (265 shoulders), the cement used for humeral fixation did not have antibiotics; in group 2 (236 shoulders), antibiotic-impregnated bone cement containing tobramycin, gentamycin, or vancomycin/tobramycin was used for fixation.Results: At an average postoperative follow-up of 37 months, no deep infection had developed in the 236 shoulders in group 2, whereas a deep infection had developed in 8 of the 265 shoulders (3.0%) in group 1. This difference between the groups was significant (P < .001).Conclusions: Antibiotic-impregnated bone cement was effective in the prevention of postoperative deep infection after primary reverse total shoulder arthroplasty during short-term follow-up.

A quantitative three-dimensional templating method for shoulder arthroplasty: biomechanical validation in cadavers - Corrected Proof

2011-12-05

Background: Press-fit humeral components for total shoulder arthroplasty have notable potential complications that may be minimized by preoperative templating and improvements in stem design. The purpose of this study was to develop a 3-dimensional templating technique for the humeral stem and to validate this templating in cadaveric specimens.Materials and methods: A cylindrical stem and a stem with a rectangular cross-section were selected for templating and force measurements. Templating was carried out for 15 clinical patients and 16 cadaveric shoulders, including calculation of the cortical-implant volume ratio (CIVR). Insertion forces for stem broaching and impaction were measured for 15 patients and 8 paired cadaveric shoulders. Hoop strain and periprosthetic fractures were monitored in cadaveric shoulders with strain gauges.Results: A significant difference in the CIVR was noted between rectangular and cylindrical stems. No difference was observed in impact forces for ideally sized rectangular or cylindrical stems. A difference in insertion forces was found between oversized cylindrical and oversized rectangular implant stems and also between ideal and oversized cylindrical implant stems. The difference in maximal hoop strain between ideally sized rectangular and cylindrical stems was also statistically significant.Conclusions: CIVR is useful to predict an ideal humeral stem size. Cylindrical stems have a different design rationale for fixation than rectangular stems. Surgeon awareness of the fixation rationale for a particular stem design is important because different stem types have different effects on the insertion force. More anatomic humeral stem designs may help to minimize the risk of complications and optimize stem fixation.

Comparisons of glenoid bony defects between normal cadaveric specimens and patients with recurrent shoulder dislocation: an anatomic study - Corrected Proof

2011-12-05

Background: The location and degree of bony defects that can affect clinical outcomes remains controversial in recurrent shoulder dislocation. The purpose of this study was to define the most common location of glenoid bony defects in patients with recurrent shoulder dislocation.Materials and methods: We analyzed the shape and aspect ratio of 44 glenoids from deceased donors. Glenoid size was analyzed using a 3-dimensional (3D) computed tomography (CT) scan in 24 patients with recurrent shoulder dislocation who underwent arthroscopic Bankart repair. We measured the distances from the center of the longitudinal axis of the glenoid to the anterior glenoid rim at 9 positions, 10° apart, from 3:00 to 6:00 o’clock positions in the cadaver and patient groups. We compared the quantification of glenoid defects in the 24 patients using the 3D CT scan. A predictive model based on a discriminant analysis was developed.Results: The largest length differences of the glenoid were at the 3:20 o’clock position. When percentage of bone antidefect of the 3:20 o’clock position was used, the model predicted the existence of a defect with 89.7% hit ratio.Conclusions: The major direction of the glenoid defect was in a more anterior position rather than the anteroinferior glenoid in patients with recurrent shoulder dislocation. The 3:20 o’clock position was most common location of glenoid defect in shoulder instability. This pattern of bone loss should be considered by the surgeon when operating on these patients, especially when performing arthroscopic procedures for Bankart repair or bone block operations to the glenoid.

Feasibility of contralateral trapezius transfer to restore shoulder external rotation: part I - Corrected Proof

Bassem T. Elhassan, Eric R. Wagner, Allen T. Bishop — 2011-12-05

Purpose: We evaluated the feasibility of contralateral trapezius transfer to restore shoulder external rotation.Materials and methods: The length of the lower trapezius and distance necessary for contralateral trapezius transfer were measured in 20 volunteers and directly in 12 cadavers. The average distances between the medial spine of the scapula and T12 (length of lower trapezius) and the spine to the greater tuberosity (distance for transfer) were measured with the scapula neutral, maximally protracted, and maximally retracted. In cadavers, the origin of the lower trapezius was detached, transferred to the contralateral greater tuberosity, and retracted to determine its effectiveness in external rotation and tension on the vascular pedicle.Results: In volunteers, the average difference between the length of the lower trapezius and the transfer distance was 19 mm in neutral. When the scapula was protracted and retracted, the difference was 79 and −49 mm. In the cadavers, the average transfer distance (in mm) was 290 ± 12, 365 ± 15, and 209 ± 25 in the neutral, protracted, and retracted positions, respectively. The average length of the lower trapezius (in mm) was 270 ± 10, 285 ± 12, and 258 ± 10 in the neutral, protracted, and retracted positions. The transfer was universally feasible when the scapula was partially retracted. Prolongation of the lower trapezius with lumbar fascia made the transfer possible in all scapular positions. Pulling on the transferred muscle resulted in contralateral shoulder external rotation without tension or impingement on the neurovascular pedicle.Conclusion: Contralateral trapezius transfer to the infraspinatus insertion appears feasible and potentially effective in restoration of shoulder external rotation.

Regarding “Editor's Note” - Corrected Proof

Edward B. Self — 2011-11-24

I was most interested in your excellent Editor's Note regarding the 46-year-old woman with an “overuse” work-related injury to her shoulder, appearing in the recent September issue of the Journal of Shoulder and Elbow Surgery. I believe there are two key issues relating to your discussion that may benefit amplification.

Management of deep infection after reverse total shoulder arthroplasty: a case series - Corrected Proof

2011-11-21

Background: Reverse total shoulder arthroplasty (RSA) is being increasingly used in the treatment of disabling shoulder conditions. This study reports the management of deep infections after RSA.Materials and methods: Eight of 138 patients were treated for deep infection after the index procedure. A retrospective review was performed to identify risk factors, methods of management, and determine ultimate outcome. A minimum of 12-month follow-up was available in 7 of 8 patients.Results: Six infections occurred in patients who had had previous shoulder surgery. The causative bacterial organism was identified in 6 patients. Deep infection occurred in 3 patients with diabetes mellitus. Antibiotic cement was used in all cases. Six patients were managed with irrigation and debridement and retention of components. Two patients with of Staphylococcus aureus infection ultimately required resection arthroplasty. Patients managed with irrigation and debridement, intravenous antibiotics, and retention of components demonstrated good pain relief and function, without evidence of radiographic loosening. Resection resulted in pain relief but poor functional outcomes.Conclusion: Limited literature is available regarding the management of deep infection in patients with RSA. Component removal after a RSA creates increased bone loss due to a cemented humeral component and glenoid baseplate with several large screws. Five of 7 patients with deep infection had undergone previous shoulder surgery. We recommend that patients should be managed with an initial irrigation and debridement, appropriate intravenous antibiotics, and component retention.

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

Thilo Patzer, Peter Habermeyer — 2011-11-21

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

Ulnar component surface finish influenced the outcome of primary Coonrad-Morrey total elbow arthroplasty - Corrected Proof

In-Ho Jeon, Bernard F. Morrey, Joaquin Sanchez-Sotelo — 2011-11-21

Background: Controversy remains regarding the mechanisms leading to ulnar loosening after elbow replacement. We therefore assessed the loosening rate of the ulnar component as a function of the surface finish of a commonly used implant design.Materials and methods: This study included 3 groups who received implants with 3 different surface finishes: sintered beads (278 components), polymethylmethacrylate precoating (219 components), and plasma-sprayed beads (205 components).Results: The 3 groups who received the implants did not differ statistically in age, sex, or underlying diagnosis. The rates of mechanical failure for the sintered, precoated, and plasma-sprayed ulnar components were 6.8%, 12.8%, and 0%, respectively. The 7-year Kaplan-Meier survival rates free of mechanical failure were 93.1% for the sintered-beads group, 83.1% for the precoated group, and 100% for the plasma-sprayed group. Failed precoated ulnar components often failed early and exhibited typical features, including proximal debonding and severe focal or global osteolysis, sometimes leading to periprosthetic insufficiency fractures.Conclusion: Precoating the ulnar component with polymethylmethacrylate can lead to an increased rate of loosening and severe osteolysis. A plasma-sprayed ulnar component is associated with a very low mechanical failure rate with surveillance of less than 10 years.

Additional x-ray views increase decision to treat clavicular fractures surgically - Corrected Proof

2011-11-18

Background: The trauma series for clavicular fractures includes anterior-posterior and 20° cephalic tilt radiographs. Management of clavicular fractures either nonoperatively or operatively is dependent on radiographs. We hypothesized that the interobserver and intraobserver reliability of the treatment decision would be improved with a novel 4-view radiographic series over the standard 2-view radiographic trauma series.Methods: Four-view radiographic analysis was performed and consisted of anterior-posterior, 20° cephalic tilt, 45° cephalic tilt, and 45° caudal tilt. Radiographs were collected for 50 consecutive patients presenting with acute midshaft clavicular fractures. Four blinded orthopedists were asked to judge whether each case should be treated either operatively or nonoperatively based on the standard 2-view series and then the 4-view series a minimum of 1 week later. This procedure was repeated a minimum of 2 months later. The incidence of surgeon treatment modification was analyzed along with interobserver and intraobserver reliability of both series.Results: In 17 cases, at least 1 surgeon changed the treatment decision between 2- and 4-view review. In 13 cases (26%), the treatment was changed from nonoperative to operative. Significantly greater intraobserver reliability was observed for the 4- versus 2-view series (R = 0.76 and R = 0.64, respectively), with no difference in interobserver reliability (intraclass correlation coefficient of 0.88 and 0.87, respectively).Conclusions: With the use of a novel 4-view radiographic series that includes orthogonal viewing angles, surgeons are more likely to treat clavicular fractures operatively and their intraobserver reliability is improved, suggesting improved visualization of anterior-posterior displacement.

Effects of posterior capsule tightness on subacromial contact behavior during shoulder motions - Corrected Proof

2011-11-14

Background: Although posterior capsule tightness is believed to cause abnormal contact in the subacromial space, it is not clear whether this tightness changes the contact between the acromion and humeral head.Materials and methods: Nine fresh, frozen cadaveric shoulders were used to measure contact pressure on the coracoacromial arch during passive flexion, abduction, and internal and external rotation at 90° of elevation in the scapular plane, as well as horizontal adduction and abduction. The site where the peak contact pressure occurred was also observed. The posterior capsule in the region from 8 to 10 o’clock in the right shoulder was plicated to simulate posterior capsule tightness.Results: Peak contact pressure significantly increased with the tightened posterior capsule during flexion. Although peak contact pressure on the coracoacromial ligament during internal rotation significantly increased after capsule tightening, there was no significant increase in pressure when considering the entire coracoacromial arch. The angle where the peak contact pressure occurred during flexion was not significantly far from the end range. The site of the peak contact pressure in 7 of 9 shoulders was on the lesser tuberosity during flexion, regardless of the posterior capsule tightness.Conclusions: Posterior capsule tightness increased contact pressure mainly on the lesser tuberosity during flexion. The peak contact pressure occurred close to the end range of flexion, mainly on the lesser tuberosity. These findings are useful to understand the contribution of posterior capsule tightness to subacromial contact.

Glenoid morphology rather than version predicts humeral subluxation: a different perspective on the glenoid in total shoulder arthroplasty - Corrected Proof

Heinz R. Hoenecke, Lisa M. Tibor, Darryl D. D'Lima — 2011-11-14

Background: Glenoid retroversion is thought be important in shoulder stability before and after shoulder arthroplasty; thus, many authors recommend glenoid reaming to correct retroversion and improve stability. Genetic analysis has revealed that glenoid vault and scapular development are controlled by different genes and environmental factors, resulting in diverse glenoid morphologies. We therefore analyzed the relative contribution of glenoid morphology and version to humeral head position.Materials and methods: We obtained 121 shoulder computed tomography scans preoperatively for shoulder arthroplasty. Humeral subluxation and glenoid version were measured on the axial image at the middle of each glenoid. Glenoid morphology was characterized as biconcave, worn, displaced, dysplastic, angled, or neutral. The strength of the correlation between humeral subluxation, glenoid version, and glenoid morphology was analyzed.Results: Glenoid version did not correlate with humeral subluxation. The highest frequency of posterior subluxation was noted in biconcave glenoids. Shoulders with other glenoid morphologies were more likely to have anterior or central positioning of the humerus. The mean subluxation ratio for biconcave glenoids was 0.56 and was significantly different from all other morphologies (P < .02).Discussion/Conclusion: Even in the arthritic shoulder, glenoid orientation does not appear to explain the complex biomechanics of shoulder stability. The causes of humeral head subluxation before and after total shoulder arthroplasty are likely multifactorial and may include static and dynamic soft-tissue forces. The biconcave glenoid deserves more attention at surgery because of the high association with posterior subluxation.

Tensile and shear mechanical properties of rotator cuff repair patches - Corrected Proof

Salma Chaudhury, Chris Holland, Mark S. Thompson, Fritz Vollrath, Andrew J. Carr — 2011-11-14

Background: Augmentation of rotator cuff tears aims to strengthen the repair and reduce rerupture, yet studies still report high failure rates. This study determines key mechanical properties of rotator cuff repair patches, including establishing values for toughness and measuring the shear properties of repair patches and human rotator cuff tendons. We hypothesized that different repair grafts would (1) have varying material parameters, and (2) not all have mechanical properties similar to human rotator cuff tendons.Materials and methods: Eight specimens each from the Restore, GraftJacket, Zimmer Collagen Repair, and SportsMesh repair patches were tested to failure in tension and for suture pullout. We assessed ultimate tensile strength, tensile (Young’s) modulus, and failure strain. This study also established toughness values and shear data. Storage modulus was calculated using dynamic shear analysis for the patches and 18 samples of normal rotator cuff tendon.Results: We report significant variability in important mechanical properties of repair patches, with the mechanical parameters of the patches diverting variously—and often significantly—from values for human rotator cuff tendon.Conclusions: The repair grafts tested all displayed significant variation in their mechanical properties and had at least some reduced parameters compared with human rotator cuff tendons. This study offers experimentally derived information of value to surgeons when selecting rotator cuff repair grafts. A better understanding of the mechanical suitability of repair grafts for supporting human rotator cuffs is needed if repair patches are to provide a solution for the clinical problem of failure of rotator cuff repairs.