Journal of Shoulder and Elbow Surgery - Articles in Press

Humeral head arthroplasty and its ability to restore original humeral head geometry - Corrected Proof

Fraser Harrold, Carlos Wigderowitz — 2012-05-16

Background: Modern prosthetic components are designed to enable restoration of proximal humeral morphology, provided that a precise osteotomy of the humeral head at the level of the anatomic neck is performed. To determine whether a simulated osteotomy and replacement arthroplasty with an idealized implant were able to restore original head geometry.Materials and methods: A handheld digitizer and surface laser scanner were used to digitize 24 humeri. Computer models were used to simulate an osteotomy, performed at the anterior cartilage–metaphyseal interface, and reconstruct the head with a spherical prosthetic head. The head diameter, radius of curvature, and inclination and retroversion angles were calculated for each specimen and compared with the original humeral head.Results: The simulated osteotomy resulted in a 4.8° decrease in inclination (P < .01) and 11.3° increase in retroversion (P < .001). The radius of curvature in the coronal plane was not significantly different (P = .284). However, in the axial plane, the prosthesis was significantly larger than the original head for both head diameter (P < .001) and radius of curvature (P < .05).Discussion: The study suggests that the humeral head is not a perfect segment of a sphere and an osteotomy along the anterior cartilage–metaphyseal interface does not remove only the proximal humeral articular surface. Even with a fully adaptable prosthetic implant, replacement arthroplasty is not able to restore original head geometry.Conclusions: Alterations to head geometry with the osteotomy described may alter the line of force through the prosthetic joint, producing eccentric loading at the glenoid, and contribute to early failure.

Pilomatricoma of the upper arm in an orthopaedic clinic - Corrected Proof

Ansar Vance, William H. Seitz — 2012-05-10

First described in 1880 as the “calcifying epithelioma” by Malherbe and Chenantais, the pilomatricoma was thought to be a calcifying tumor derived from sebaceous glands. Almost 70 years later, in 1949, Lever and Griesemer postulated the tumor to originate from hair follicle matrix cells. After further confirmation by light and electron microscopic studies, as well as immunohistochemical studies, Forbis and Helwig proposed the name “pilomatrixoma” in 1961. Some consider “pilomatricoma” a more etymologically proper spelling. “Calcifying epithelioma of Malherbe” is still used as well. Over a century after its introduction, our basic knowledge of this uncommon tumor is still developing. In 2009 Kurokawa et al showed that pilomatricomas could differentiate not only toward the hair follicle matrix cells but also toward the hair cortex, infundibulum, outer root sheath, and hair bulge.

The natural evolution of neglected lesser tuberosity fractures in skeletally immature patients - Corrected Proof

Sofie Goeminne, Philippe Debeer — 2012-05-10

Isolated avulsions of the lesser humeral tuberosity are rare injuries and only account for approximately 2% of all fractures of the proximal humerus. In skeletally immature patients, these fractures tend to be even more unusual. The fact that lesser tuberosity fractures in children are uncommon injuries is reflected in the paucity of literature on the management and outcome of these injuries. The first avulsion of the lesser tuberosity was described in 1895 in a 17-year-old boy with an ipsilateral humeral fracture. In 1985, White and Riley were the first to publish a formal report an isolated subscapularis avulsion in a child. So far, 33 cases of isolated avulsions of the lesser tuberosity in adolescent patients (patients aged < younger than 21 years) have been reported (). One of the main reasons is that the diagnosis of this injury is not easy and often leads to a delayed diagnosis. We report 2 patients with neglected lesser tuberosity fractures during childhood and their late treatment. We also report a patient with an acute injury, treated surgically, with an excellent functional outcome.

Cementless surface replacement arthroplasty of the shoulder for osteoarthritis: results of fifty Mark III Copeland prosthesis from an independent center with four-year mean follow-up - Corrected Proof

2012-05-10

Purpose: Few studies have reported the outcome of cementless surface replacement (CSRA). We initiated this study to analyze results of the Mark III Copeland prosthesis used as a hemiarthroplasty in patients with glenohumeral osteoarthritis.Materials and methods: We retrospectively reviewed 53 consecutive Mark III Copeland CRSA hemiarthroplasties in 46 patients (30 women, 16 men) with glenohumeral osteoarthritis from an independent institution by a single surgeon. Patients were a mean age of 69 years (range, 45-94 years). Mean follow-up was 4.2 years (range, 2-8 years). Fifty uncemented hemiarthroplasties were available for review.Results: Mean (range) age-adjusted Constant and Oxford scores improved from 38.5 (15-61) and 22 (9-31) to 75.1 (38-87) and 42 (18-48), respectively. Anterosuperior escape of the humeral head developed in 1 patient who had an oversized humeral component due to progressive rotator cuff failure at 2 years. Moderate glenoid erosion was present in 12% and correlated with oversizing of the humeral component. There was one revision to a stemmed cemented hemiarthroplasty for periprosthetic fracture. No patients have required revision for aseptic loosening, rotator cuff failure, or glenoid erosion to date.Conclusions: Copeland surface replacement hemiarthroplasty for glenohumeral osteoarthritis can provide functional results similar to modular stemmed prostheses, with a relatively low revision rate at 4.2 years of follow-up; however, there is high rate of glenoid erosion that may complicate future revision surgery, and we did not achieve the same functional improvement as that achieved from the designer’s institution.

Biomechanical effectiveness of different types of tendon transfers to the shoulder for external rotation - Corrected Proof

Robert U. Hartzler, Jonathan D. Barlow, Kai-Nan An, Bassem T. Elhassan — 2012-05-10

Background: Our purpose was to determine and compare the external rotation moment arm (ERMA) of the latissimus dorsi (LD), teres major (TM), and lower trapezius (LT) when transferred to selected locations on the proximal humerus. We hypothesize that the LT transfer has a higher ERMA compared with LD or TM.Materials and methods: Six fresh frozen cadaveric hemithoraces were used in a novel experimental design. The tendon and joint displacement method was used to calculate ERMA for 6 transfer pairs: LD to superolateral humeral head (SHH), LD to proximal-lateral humeral diaphysis (LHD), TM to SHH, TM to LHD, LT to infraspinatus insertion (ISI), and LT to teres minor insertion (TMI).Results: Tendon transfer pair had a significant effect on ERMA (P < .001), with a significant interaction effect between tendon transfer and position of the humerus (P < .0001). With the humerus at 0° abduction, the ERMAs of the LT-ISI (28.1 mm) or LT-TMI (22.3 mm) transfers were significantly higher than the ERMAs of LD-SHH (10.6 mm; P = .0001, P = .04) or LD-LHD (6.5 mm; P < .0001, P < .001). Also, ERMAs of LT-ISI and LT-TMI transfers were significantly higher than ERMA of TM-LHD (10.4 mm; P = .0001, P = .03).Conclusions: Shoulder external rotation tendon transfers differ in effectiveness and may be affected by arm position. LT potentially results in superior restoration of shoulder external rotation with the arm at the side compared with LD and should be considered as a potential tendon transfer to restore external rotation in selected patients.

Electromyographic analysis of the rotator cuff in postoperative shoulder patients during passive rehabilitation exercises - Corrected Proof

2012-05-07

Background: Numerous rehabilitation protocols exist for postoperative rotator cuff repairs. Because the goal of early rehabilitation is to prevent postoperative adhesions while protecting the repaired tendons, it would be advantageous to know which range-of-motion exercises allow the rotator cuff to remain the most passive in a painful, guarded, postsurgical shoulder.Methods: Twenty-six subjects who had undergone subacromial decompression, distal clavicle resection, or a combination of both procedures volunteered to participate within the first 4 days after surgery. Fine-wire electrodes were inserted into the subject's supraspinatus (SS) and infraspinatus (IS). Muscle activity was recorded at resting baseline (BL) and during 14 exercises that have been found in the passive phase of rotator cuff protocols and tested in healthy subjects. Each exercise was compared with BL activity as well as with other exercises in the same movement group.Results: The SS remained as passive as BL during therapist- and self-assisted external rotation, therapist-assisted elevation, pendulums, and isometric internal rotation and adduction. The IS was activated greater than BL for all 14 exercises studied.Conclusion: Of the 14 exercises studied, 6 allowed the SS and 0 allowed the IS to remain as passive as quiet-stance BL in postsurgical subacromial decompression/distal clavicle resection patients.

Biomechanical effect of latissimus dorsi tendon transfer for irreparable massive cuff tear - Corrected Proof

2012-05-07

Background: The purpose of this study was to determine the biomechanical effects of latissimus dorsi transfer in a cadaveric model of massive posterosuperior rotator cuff tear.Methods: Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane with anatomically based muscle loading. Humeral rotational range of motion and the amount of humeral rotation due to muscle loading were measured. Glenohumeral kinematics and contact characteristics were measured throughout the range of motion. After testing in the intact condition, the supraspinatus and infraspinatus were resected. The cuff tear was then repaired by latissimus dorsi transfer. Two muscle loading conditions were applied after latissimus transfer to simulate increased tension that may occur due to limited muscle excursion. A repeated-measures analysis of variance was used for statistical analysis.Results: The amount of internal rotation due to muscle loading and maximum internal rotation increased with massive cuff tear and was restored with latissimus transfer (P < .05). At maximum internal rotation, the humeral head apex shifted anteriorly, superiorly, and laterally at 0° of abduction after massive cuff tear (P < .05); this abnormal shift was corrected with latissimus transfer (P < .05). However, at 30° and 60° of abduction, latissimus transfer significantly altered kinematics (P < .05) and latissimus transfer with increased muscle loading increased contact pressure, especially at 60° of abduction.Conclusion: Latissimus dorsi transfer is beneficial in restoring humeral internal/external rotational range of motion, the internal/external rotational balance of the humerus, and glenohumeral kinematics at 0° of abduction. However, latissimus dorsi transfer with simulated limited excursion may lead to an overcompensation that can further deteriorate normal biomechanics, especially at higher abduction angles.

Surgical treatment of anterior instability in rugby union players: clinical and radiographic results of the Latarjet-Patte procedure with minimum 5-year follow-up - Corrected Proof

2012-05-07

Background: Anterior instability in rugby players is characterized by the common finding of a bony lesion, which has been identified as a potential cause of recurrence after soft-tissue reconstruction. The Latarjet-Patte procedure is effective in the treatment of recurrent anterior instability in collision sports such as rugby union.Methods: We retrospectively assessed 34 rugby players (37 shoulders) stabilized with the Latarjet-Patte procedure. The mean follow-up was 12 years. All patients underwent clinical and radiographic assessment preoperatively and at final follow-up. Functional evaluation was performed with the Walch-Duplay and Rowe scores. A visual analog scale score for the evaluation of pain and the subjective shoulder value were recorded. In addition, all patients completed a questionnaire regarding the return to playing rugby.Results: No recurrence of either dislocation or subluxation occurred. Persistent apprehension on clinical examination was present in 5 patients (14%). A bony lesion of the glenoid was present in 73% and a Hill-Sachs lesion in 68%. Sixty-five percent of the patients returned to playing rugby; only 1 patient did not return to playing rugby because of his shoulder. The mean Walch-Duplay and Rowe scores were 86 and 93 points, respectively. The mean subjective shoulder value was 90%. Radiographic healing of the bone block was observed in 89% of cases. At final follow-up, 11 patients (30%) had minor arthritic changes, with no cases of moderate or severe arthritis.Conclusion: The Latarjet-Patte procedure provides a reliable method for stabilizing the shoulder, resulting in a return to playing rugby in a high number of cases without increasing the risk of long-term arthritic degradation.

Accuracy of obtaining optimal base plate declination in reverse shoulder arthroplasty - Corrected Proof

2012-05-04

Background: Reverse total shoulder arthroplasty has shown promising early and midterm results; however, complication rates remain a concern. Glenoid loosening and notching, for example, can be deleterious to the long-term success. A 15° inferior inclination angle has been shown to offer the most uniform compressive forces across the base plate and the least micromotion at the base plate–glenoid interface. The inferior inclination angle may also avoid scapular notching. The purpose of this study was to determine the accuracy of obtaining 15° of inferior inclination of the base plate.Methods: The radiographs of 138 reverse total shoulder patients were included. Overall, glenoid inclination and change in inclination from preoperative radiographs were measured using a previously described standardized method. Measurements were obtained by 2 orthopedic surgeons, who repeated all measurements 3 weeks apart. The final angle and change in inclination were averaged.Results: Seventy-two patients had pre- and postoperative radiographs of sufficient quality to accurately measure inclination. Average pre- and postoperative inclination measured −4.8° (−27.2° to 28.1°) and −13.3° (−22.8° to 43.6°), respectively. The average change in inclination was −8.5° (−53.7o to 34.6o). No scapular notching was observed, which may relate to the lateralized center of rotation of the implant used in this study.Discussion: Overall, the average decrease in inclination was very close to the intended target value using the standard guide. However, patients with preoperative superior glenoid erosion from advanced rotator cuff tear arthropathy appeared to be consistently tilted superiorly, suggesting the standard guide may be inadequate in these patients.

Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol - Corrected Proof

Derek J. Cuff, Derek R. Pupello — 2012-05-04

Background: This study evaluated patient outcomes and rotator cuff healing after arthroscopic rotator cuff repair using a postoperative physical therapy protocol with early passive motion compared with a delayed protocol that limited early passive motion.Materials and methods: The study enrolled 68 patients (average age, 63.2 years) who met inclusion criteria. All patients had a full-thickness crescent-shaped tear of the supraspinatus that was repaired using a transosseous equivalent suture-bridge technique along with subacromial decompression. In the early group, 33 patients were randomized to passive elevation and rotation that began at postoperative day 2. In the delayed group, 35 patients began the same protocol at 6 weeks. Patients were monitored clinically for a minimum of 12 months, and rotator cuff healing was assessed using ultrasound imaging.Results: Both groups had similar improvements in preoperative to postoperative American Shoulder and Elbow Surgeons scores (early group: 43.9 to 91.9, P < .0001; delayed group: 41.0 to 92.8, P < .0001) and Simple Shoulder Test scores (early group: 5.5 to 11.1, P < .0001; delayed group: 5.1 to 11.1, P < .0001). There were no significant differences in patient satisfaction, rotator cuff healing, or range of motion between the early and delayed groups.Conclusions: Patients in the early group and delayed group both demonstrated very similar outcomes and range of motion at 1 year. There was a slightly higher rotator cuff healing rate in the delayed passive range of motion group compared with the early passive range of motion group (91% vs 85%).

Are there advantages of the combined latissimus-dorsi transfer according to L’Episcopo compared to the isolated latissimus-dorsi transfer according to Herzberg after a mean follow-up of 6 years? A matched-pair analysis - Corrected Proof

Sven Lichtenberg, Petra Magosch, Peter Habermeyer — 2012-04-30

Hypothesis: The aim of the study was to evaluate differences of clinical results between the latissimus-dorsi transfer combined with teres-major transfer (G1) and the isolated latissimus-dorsi transfer (G2) for the treatment of massive irreparable postero-superior rotator cuff tears.Methods: We performed the combined latissimus-dorsi/teres-major transfer in 17 patients at a mean age of 57 years. Furthermore, 17 patients at a mean age of 61 years were treated using the isolated latissimus-dorsi transfer. Both groups were followed-up clinically, radiologically, and with surface electromyography using the same study protocol.Results: The Constant score (CS) improved significantly from 48.3 points pre-op to 69.5 points post-op after a follow-up of 58 months in G1. The active range of motion improved in G1 sig. for flexion (124° pre-op, 166.5° post-op) and for abduction (117° pre-op, 163° post-op). The CS improved significantly from 45.1 points pre-op to 74.2 points post-op after a follow-up of 51 months in G2. The flexion and abduction increased significantly from 133.3° pre-op to 176° post-op, resp. from 113.3° pre-op to 173° post-op. The comparison of both surgical techniques showed a significant better active flexion and abduction for G2.Conclusion: Both techniques achieved good functional results but the isolated latissimus-dorsi transfer produced a better active abduction and flexion, whereas the combined latissmus-dorsi/teres-major transfer achieved an increase in abduction strength. In contrast to the combined latissimus-dorsi/teres-major transfer, a progression of cuff tear arthropathy was not observed with the isolated latissimus-dorsi transfer.

Ganglion cyst of the spinoglenoid notch: Comparison between SLAP repair alone and SLAP repair with cyst decompression - Corrected Proof

Doo-Sup Kim, Hyeun-Kook Park, Jang-Hee Park, Won-sik Yoon — 2012-04-30

Background: Some authors have described the ganglion cyst of the spinoglenoidal notch as related to repetitive overhead activities and labral tear caused by trauma, while others have explained lesions of the capsulolabral complex and ganglion cysts to have separate pathologies. The purpose of this study is to compare clinical and radiological outcomes between 2 groups: 1 with superior labrum anterior and posterior (SLAP) repair only and the other with SLAP repair and cyst decompression prospectively.Materials and methods: From August 2000 to March 2007, 28 patients matching the inclusion criteria were selected for the study. They were divided into 2 groups: 1 who received SLAP repair and the other with concomitant SLAP repair and cyst decompression. A visual analogue scale (VAS) and Rowe and Constant scores were used to make evaluation. Preoperative magnetic resonance images (MRIs) of 2 patient groups were compared with 2 follow-up MRIs taken 3 months after the operation and at final follow-up.Results: Mean VAS and Constant and Rowe scores in groups I and II improved significantly from mean preoperative score compared to last follow-up score; however, there was no statistically significant difference between the 2 groups (P > .05). Preoperative MRI and arthroscopy revealed type II SLAP lesions and a type V lesion, respectively, as accompanying lesions in 24 cases.Conclusion: The hypothesis stating 1-way valve mechanism of SLAP lesion as an initial cause of ganglion cysts has been proved indirectly in this study. Furthermore, direct decompression of the cyst does not lead to different results.

Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures: a staged protocol - Corrected Proof

2012-04-30

Introduction: This study determined outcomes after temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures.Materials and methods: A retrospective case analysis was done of all patients who were treated between 2000 and 2008 in 3 level I trauma centers with temporary joint-spanning external fixation before internal fixation of an open intra-articular distal humeral fracture. Healing rates, complications, Disabilities of Arm, Shoulder and Hand (DASH), and Smith and Cooney outcome scores were documented.Results: The study included 16 patients. Mean follow-up was 35.2 months. Fractures united after an average of 5.2 months. No complications specifically related to the external fixation occurred. The DASH outcome score averaged 15.1. Although complications occurred in 12 patients (9 patients requiring surgery), 10 of 16 had an excellent/good outcome score.Conclusions: Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunct.

Clavicle morphometry revisited: a 3-dimensional study with relevance to operative fixation - Corrected Proof

Abdo Bachoura, Andrew S. Deane, James N. Wise, Srinath Kamineni — 2012-04-30

Background: The advocacy for operative fixation of midshaft clavicle fractures has prompted a reemergence of interest in clavicle anatomy. Three-dimensional (3D) anatomical studies provide more information than 2-dimensional studies, but are currently rare.Material and methods: Twenty-five skeletonized clavicles were digitized using a laser scanner. Three-dimensional computer software was used to analyze the data. Clavicles were divided into medial, middle, and lateral segments based on the medial and lateral apices of curvature and their lengths and midpoint cortical diameter measured. The angles of medial and lateral curvatures were measured in standardized axial and coronal planes. The medial and lateral curvatures were fitted with circles and the radii of curvature measured. Correlations between the intrinsic dimensions of the clavicle were assessed.Results: The mean length was 136.7 mm. The medial, middle, and lateral segments had mean lengths of 48, 56, and 32.7 mm, respectively. In the axial plane, the mean medial and lateral angles were 149.5° and 145.8°, respectively. In the coronal plane, the mean medial and lateral angles were 178.2° and 174.2°, respectively. The mean midpoint cortical diameter was 10.9 mm. The mean medial and lateral radii of curvature were 66.4 and 33.5 mm, respectively. The length and cortical diameter and length and medial radius of curvature were found to positively correlate, R2 = .355 and .184, respectively.Conclusion: Using standardized measurements, we were able to accurately characterize the dimensions of the clavicle. We found that the length of the clavicle correlates with the midpoint cortical diameter and with the radius of medial curvature.

Acromioclavicular joint reconstruction: a comparative biomechanical study of three techniques - Corrected Proof

2012-04-30

Background: Acute acromioclavicular joint dislocations indicated for surgery can be treated with several stabilization techniques. This in vitro study evaluated the acromioclavicular joint stability after 3 types of validated repair techniques compared with the native situation.Materials and methods: Nine pairs (right-left) of intact cadaveric shoulder specimens were assigned to 3 study groups with randomly distributed samples according to the coracoclavicular distance. The groups were instrumented with acromioclavicular and coracoclavicular cerclages (CE), a Twin Tail TightRope (TR), or a locking compression superior and anterior clavicle plate (CP). Native and instrumented specimens were tested quasi-static nondestructively (superior: 70 N; anteroposterior: ±35 N, 10 mm/min) and cyclically until failure (superior, valley load: 20 N; initial peak load: 70 N; increment: 0.02 N/cycle).Results: The TR study group showed the highest (in N/mm) superoinferior (73.77 ± 14.04) and anteroposterior (29.58 ± 1.52) stiffness, followed by CE (superoinferior: 59.73 ± 10.33; anteroposterior: 24.31 ± 4.14) and CP (superoinferior: 24.08 ± 5.29). Instrumentation generally led to increased superoinferior and anteroposterior stiffness in each study group but to a significant superoinferior stiffness reduction for CP (P = .029). Significantly lower coracoclavicular displacement at valley load after 1 and 500 cycles was observed for TR (P = .018) and CE (P = .041) compared with CP. Cycles to failure were significantly higher in CE (7298 ± 1244 cycles, P = .011) and TR (4434 ± 727 cycles, P = .031) compared with CP (1683 ± 509 cycles).Conclusions: The CE and TR techniques led to similar biomechanical performances. The CE repair might mimic the native acromioclavicular joint stiffness better than the other 2 setups, leading to more physiological stabilization.

Bone marrow-derived cells from the footprint infiltrate into the repaired rotator cuff - Corrected Proof

2012-04-30

Background: Cells from the bone marrow are considered important during the rotator cuff repair process, but the kinetics of bone marrow-derived cells in this process is unknown.Purpose: To analyze the kinetics of bone marrow cells during the rotator cuff repair process, to review whether or not they are histologically involved in rotator cuff healing, and to analyze the biomechanics of the repaired tissues.Methods: Bone marrow chimeric rats that express green fluorescent protein (GFP) only in bone marrow- and circulation-derived cells were created. Bilateral supraspinatus tendons were separated from the greater tuberosity of the humeral head to produce a rotator cuff transection model. Drilling into the bone marrow was performed in the greater tuberosity of the right humerus and the supraspinatus tendon was repaired (drilling group), while the supraspinatus tendon was repaired on the left shoulder without drilling (control group). We examined the histology of the rotator cuff, the ultimate force-to-failure, and the proportion of GFP-positive cells in the repaired rotator cuff at 2, 4 and 8 weeks after surgery.Results: Mesenchymal cells were observed in the repaired rotator cuff at 2 weeks in both groups. There were more GFP-positive cells in the drilling group than the control group at 2, 4 and 8 weeks. The ultimate force-to-failure was significantly higher in the drilling group than the control group at 4 and 8 weeks.Conclusion: Bone marrow-derived cells passed through holes drilled in the humerus footprint, infiltrated the repaired rotator cuff and contributed to postsurgical rotator cuff healing.

Functional outcomes and structural integrity after double-pulley suture bridge rotator cuff repair using serial ultrasonographic examination - Corrected Proof

2012-04-27

Background: We evaluated the integrity and functional outcomes of rotator cuff tear after performing the double-pulley suture bridge (DPSB) repair technique according to the tear size by using serial ultrasonographic examinations.Materials and methods: The study included 41 consecutive arthroscopic rotator repairs using the DPSB technique. The average follow-up was 28 months. We completed the serial ultrasonographic examinations and compared the results with the functional outcome using the American Shoulder and Elbow Surgeons (ASES) score, the Constant score, the Korean Shoulder Scoring (KSS) system, and the University of California, Los Angeles (UCLA) score.Results: The overall retear rate was 19.5% (8 of 41), comprising 50% (2 of 4) for massive tears, 18% (2 of 11) for large tears, 17% (4 of 23) for medium tears, and no failures for small tears (0 of 3). The retear rate was 17.6% (6 of 34) after complete repair and 28.6% (2 of 7) after repair with gap formation. Seventy-five percent (6 of 8) of retears were identified within 6 months after operation and 25% (2 of 8) were identified more than 1 year after repair. The functional outcomes of the intact group and the retear group according to the ASES score, the Constant score, the KSS, and the UCLA score were 96, 93, 94, and 33, and 90, 82, 87, and 31, respectively (P > .05).Conclusion: The overall retear rate after DPSB repair was 19.5% with 2 time periods of retear. The outcome improved independent of the tear size and the cuff integrity.

Fixation and durability of a bone-ingrowth component for glenoid bone loss - Corrected Proof

Thomas M. Lawrence, Shahryar Ahmadi, John W. Sperling, Robert H. Cofield — 2012-04-27

Background: Deficient glenoid bone is a reconstructive challenge in shoulder arthroplasty. One solution is an ingrowth anatomic glenoid with column and screw fixation, with or without supplemental bone graft. This study examines the outcome of patients managed in this manner.Materials and methods: This type of glenoid component was used in 21 shoulder arthroplasties with central or peripheral glenoid bone deficiencies: 13 for bone loss due to arthritic wear and 8 for revision arthroplasty. Patients were monitored clinically for a mean of 11.1 years (range, 7.6-15.1 years) and by x-ray imaging for a mean of 9.1 years (range, 2.2-14.2 years).Results: Revision procedures were needed for 7 shoulders at a mean of 10.4 years (range 5.5-14.3 years), 6 for polyethylene or metal wear leading to glenoid loosening in 4. In the 14 nonrevised shoulders, pain ratings (1 to 5 scale) decreased from a mean of 4.5 to 1.9 (P < .001). Mean active elevation increased from 100° to 125° (P = .02). Mean external rotation increased from 28° to 43° (P = .06). Results assessed by the Neer rating were excellent in 3, satisfactory in 10, and unsatisfactory in 1. In radiographic assessment of the unrevised shoulders, 4 were at risk for glenoid loosening, and 1 was at risk for humeral loosening.Conclusions: This method of reconstruction can offer pain relief and improved motion. However, the large number of revision procedures and additional adverse changes on x-ray imaging suggest other reconstructive options may be more successful and durable.

The relationship between tear severity, fatty infiltration, and muscle atrophy in the supraspinatus - Corrected Proof

2012-04-27

Background: Fatty infiltration and muscle atrophy have been described as interrelated characteristic changes that occur within the muscles of the rotator cuff after cuff tears, and both are independently associated with poor outcomes after surgical repair. We hypothesize that fatty infiltration and muscle atrophy are two distinct processes independently associated with supraspinatus tears.Materials and methods: A retrospective review of 377 patients who underwent shoulder magnetic resonance imaging at one institution was performed. Multivariate analysis was performed based on parameters including age, sex, rotator cuff tear severity, fatty infiltration grade, and muscle atrophy.Results: A total of 116 patients (30.8%) had full-thickness tears of the supraspinatus, 153 (40.6%) had partial thickness tears, and 108 (28.7%) had no evidence of tear. With increasing tear severity, the prevalence of substantial fatty infiltration (grade ≥2) increased: 6.5% of patients with no tears vs 41.4% for complete tears (P <.001). Similarly, the prevalence of supraspinatus atrophy increased with worsening tear severity: 36.1% of no tears vs 77.6% of complete tears (P < .001). Multivariate analysis demonstrated a significant independent association between fatty infiltration and muscle atrophy when taking into account sex, age, and tear severity.Conclusions: Fatty infiltration and muscle atrophy are independently associated processes. Fatty infiltration is also related to increasing age, muscle tear severity, and sex, whereas muscle atrophy is related to increasing age but not tear severity. In patients without rotator cuff tears, fatty infiltration and atrophy prevalence increased independently with increasing age.

Anatomic direct repair of chronic distal biceps brachii tendon rupture without interposition graft - Corrected Proof

Hilary A. Bosman, Matthew Fincher, Nicholas Saw — 2012-04-27

Background: Rupture of the biceps brachii insertion is relatively uncommon and may present late. Chronic ruptures pose a management dilemma, with higher reported complication rates when surgery is delayed, whilst conservatively treated injuries may do badly in active patients.Materials and methods: Six consecutive male patients with delayed presentation of biceps rupture were treated operatively using a limited standard anterior approach, a secondary proximal “retrieval” incision, and EndoButton fixation. This modification of the well-described EndoButton technique for distal biceps reconstruction allows passage of the shortened tendon in maximal elbow flexion and a rehabilitation program without immobilization. The mean interval to repair was 79 days (range, 35-116 days). The mean age at presentation was 47.5 years. The injury mechanisms were unexpected loads on a flexed supinated forearm.Results: Patients were assessed at a mean of 20.2 months. Range of motion was restored to 94% in flexion and 95% in prosupination compared with the uninjured limb. Supination endurance was reduced by 9 repetitions/min compared with the contralateral side (mean, 83.4 repetitions/min). Mayo Elbow Performance Scores were universally 100 and the mean Disabilities of Arm, Shoulder and Hand score was 4. Patient satisfaction was high, with visual analog scores of 92 to 100. No major complications occurred, and all repairs were intact at the final follow-up.Conclusions: Our outcomes are comparable to acute repair, with restoration of range of motion and function and few complications.

Effect of radial head malunion on radiocapitellar stability - Corrected Proof

Dave R. Shukla, James S. Fitzsimmons, Kai-Nan An, Shawn W. O’Driscoll — 2012-04-23

Background: Management for Mason type II radial head fractures is controversial. We hypothesized that angulation or depression of a marginal radial head fragment would affect radiocapitellar stability similarly to fragment excision.Materials and methods: A Mason type II radial head fracture was created in 6 cadaveric elbows by excising a segment from the anterolateral quadrant that was 30% of the diameter of the articular surface. Radiocapitellar stability was recorded under 5 sets of conditions: (1) intact radial head (intact), (2) 30% surface area fragment resected (partially excised), (3) anatomic fragment fixation with screws (fixed), (4) fragment fixation with 2 mm of depression relative to the articular surface (depressed), and (5) fragment fixation after a 30° wedge resection (angulated).Results: The forces required to subluxate the joint were greatly reduced after fragment excision (5 ± 1 N; P = .0001) and restored to normal (21 ± 1 N; P = .9) after anatomic fixation of the excised fragment. The peak forces were significantly reduced with fragment depression (4 ± 1 N) and angulation (4 ± 2 N; P = .0001).Conclusion: A radial head fracture that is depressed 2 mm or angulated 30° may cause up to an 80% loss of concavity-compression stability of the radiocapitellar joint.

The value of somatosensory evoked potential monitoring during scapulothoracic arthrodesis: case report and review of literature - Corrected Proof

2012-04-23

Fascioscapular humeral dystrophy (FSHD), an autosomal dominant genetic disorder affecting 1 in every 20,000 people, is characterized by development of dystrophic changes in muscles of the face, shoulder girdle, and upper limb, along with potential involvement of the lower limbs and spine. Symptoms typically present in the second decade of life and progress slowly through adulthood, resulting in limited functional capacity and vocational opportunities. In a study on careers of patients with FSHD, 23% indicated being unemployed at one time, 20% were wheelchair-dependent, 11% had obtained jobs through a sheltered workplace for the disabled, and 17% needed to change jobs as their disease progressed.

Teres minor muscle and related anatomy - Corrected Proof

Dara Chafik, Leesa M. Galatz, Jay D. Keener, H. Mike Kim, Ken Yamaguchi — 2012-04-23

Background: The purpose of this study was to describe the complex anatomy surrounding the teres minor muscle.Methods: Thirty-one cadaveric human shoulders were dissected. Qualitative fascial and neurovascular anatomy were described. Location of motor nerves to teres minor were measured in reference to local anatomy.Results: Fascial anatomy of the posterior shoulder had 2 distinct and equally common variants, 1 of which demonstrated a stout, inflexible fascial compartment enveloping the teres minor muscle. The other had a continuous fascia enveloping both the infraspinatus and teres minor muscles. In both variants, the primary nerve to teres minor traveled around a fascial sling, becoming sub-fascial at an average of 44 mm (range, 25-68) medial to the teres minor’s insertion. The nerve took its most angulated course as it entered the fascial sling. Smaller accessory innervation of teres minor began, on average, 30 mm (range, 15-48) medial to the muscle’s lateral insertion. None of the accessory motor nerves coursed deep to the fascial sling nor to the distinct teres minor fascial compartment.Conclusion: A stout fascial sling may be the potential site of greatest compression and tethering of the primary motor nerve to teres minor. Additional lateral accessory motor nerves to teres minor remained extra-fascial and took a less angulated path. Half of the shoulders demonstrated a separate teres minor fascial compartment. An improved understanding of the fascial anatomy and innervation pattern of the teres minor muscle may help clinicians who treat patients with symptomatic isolated teres minor muscle atrophy.

Proximal humeral fracture fixation: a biomechanical comparison of two constructs - Corrected Proof

2012-04-23

Background: Different options exist for stabilizing proximal humeral fractures. This study compared the mechanical stability of 2 common proximal humeral fixation plates in bending and torsion.Methods: Tests were conducted on 40 synthetic and 10 matched pairs of cadaveric humeri (evenly fixed with DePuy S3 proximal humeral plating system [DePuy Orthopaedics, Warsaw, IN, USA] and Synthes proximal humerus locking compression plate [Synthes, Paoli, PA, USA]). Half of the humeri were tested by cantilevered bending in flexion, extension, varus, and valgus for 100 cycles of ±5 mm of displacement at 1 mm/s before loading to failure in varus. The other half were tested in torsion for 100 cycles of ±8° of rotational displacement at 1°/s before loading to failure in external rotation.Results: Peak cyclic loads for synthetic constructs were higher for DePuy plates than Synthes plates in varus and valgus (P < .0001), but a difference was not detected in extension (P > .40) or flexion (P = .0675). Peak cyclic loads for cadaveric constructs showed a significant difference in extension and flexion (Synthes > DePuy, P < .0001) and in varus (DePuy > Synthes, P < .05) but not in valgus (P > .10). Bending stiffness during varus failure testing was higher for DePuy plates than Synthes plates (P < .0001) for synthetic constructs. Regarding torsion of synthetic and cadaveric constructs, DePuy plates experienced higher peak cyclic torques over all cycles in both directions (P < .0001). For synthetic constructs, DePuy plates showed higher torsional stiffness in external failure than Synthes plates (P < .0001).Conclusions: The DePuy plate was stiffer than the Synthes plate with varus and valgus bending, as well as in torsion. The Synthes plate tended to be stiffer in flexion and extension.

Three-dimensional analysis of acute plastic bowing deformity of ulna in radial head dislocation or radial shaft fracture using a computerized simulation system - Corrected Proof

2012-04-23

Background: Little 3-dimensional biomechanical investigation of plastic bowing deformity of the ulna has been reported, and the purpose of this study was to conduct such an investigation to elucidate mechanisms of injury and appropriate treatments.Methods: Ten cases of traumatic plastic deformity of the ulna in pediatric patients, 4 with chronic radial head dislocations (Monteggia equivalent) and 6 with malunited radial shaft fractures, were analyzed for rotational deformities in the axial plane and bending deformities in the sagittal and coronal planes in Euler angle space by use of a 3-dimensional computerized simulation system with a markerless registration technique.Results: Deformed ulnae with radial head dislocations had 18.7° ± 17.4° of external rotation in the axial plane and 10.4° ± 7.0° of extension in the sagittal plane whereas those with malunited radial shaft fractures had 12.5° ± 12.7° of internal rotation and 6.3° ± 5.6° of flexion displacement compared with mirror images of the opposite ulnae. Absolute values of rotational deformities in both groups were larger than those of sagittal and coronal bending deformities.Discussion: Most major traumatic plastic bowing deformities of the ulna involved rotation rather than bending. External rotational stress on the ulna is suspected to cause radial head dislocation, and internal rotational stress results in radial shaft fracture during falls onto outstretched arms. Therefore the correction of rotational deformities of the ulna should be considered in the treatment of chronic radial head dislocations and malunited radial shaft fractures.

Anatomic considerations of transclavicular-transcoracoid drilling for coracoclavicular ligament reconstruction - Corrected Proof

2012-04-23

Hypothesis: Acromioclavicular (AC) joint injuries vary in severity and damage to the AC and coracoclavicular (CC) ligaments. We hypothesized that transclavicular-transcoracoid drilling techniques, which allow for arthroscopic passage and fixation of tendon grafts in bone sockets to replace the insufficient conoid and trapezoid ligaments, cannot restore the footprints of the conoid and trapezoid ligaments without significant risk of cortical breach and coracoid fracture.Materials and methods: Data from a prospective computed tomography shoulder registry were used to create 23 distinct shoulders. Three-dimensional models were constructed the shoulders in which virtual CC ligament reconstruction tunnels were superimposed using previously described anatomic distances and landmarks.Results: Transclavicular-transcoracoid techniques resulted in mean remaining medial and lateral wall thicknesses before cortical breach of 7.3 ± 1.7 and 7.0 ± 1.6 mm, respectively. The distance from the entry point of this tunnel from the anatomic midpoint of the CC ligaments was 9.9 ± 2.2 mm. Attempts to recapitulate the CC ligament anatomy by using anatomic distances and landmarks with transcoracoid, transclavicular techniques resulted in medial cortical breach of the coracoid in 91.3% of the shoulders.Conclusion: Transclavicular-transcoracoid reconstructive techniques cannot restore the footprints of the conoid and trapezoid ligaments without significant risk of cortical breach and fracture. Attempts to correct this nonanatomic configuration by creating a tunnel based on the anatomic footprints results in a nearly universal medial cortical breach of the coracoid process.

Perforation tolerance of glenoid implants to abnormal glenoid retroversion, anteversion, and medialization - Corrected Proof

Francis Sie Hui Ting, Peter Channel Poon — 2012-04-23

Background: Loosening of the glenoid implant is a common complication of total shoulder arthroplasty. To prevent this, we need to ensure the glenoid vault is not perforated during insertion of the glenoid implant to allow for cement containment and maximum pressurization. Factors affecting perforation potential include glenoid implant design and alignment. This study looks at the perforation tolerance of 15 commercially available glenoid implants to increased retroversion, increased anteversion, and medialization.Materials and methods: Accurate 3-dimensional models of the 15 glenoid implants were created from exact dimensions obtained from the manufacturers and virtually implanted into 3-dimensional reconstructed models of 40 nonarthritic scapulae. Perforation tolerances of each implant to increased retroversion, increased anteversion, and medialization were determined through computer simulation to represent asymmetrical arthritic posterior wear, anterior wear, and eccentric corrective reaming, respectively.Results: In all 15 glenoid implants, the overall mean increased retroversion tolerated before perforation was 19°, increased anteversion was 16°, and abnormal version fully corrected by eccentric reaming was 17°. Each glenoid implant was evaluated individually to allow for direct comparison and, finally, size-matched and downsized glenoid implants in relation to the size of the humeral head.Conclusion: The results from this study help surgeons, when faced with a severely arthritic glenoid, to choose the appropriate glenoid implant to minimize perforation potential, and provide guidance on how much abnormal version and how much corrective reaming can be tolerated before perforation occurs and fixation is compromised. These results can also help with future implant designs.

Glenoid morphology after reaming in computer-simulated total shoulder arthroplasty - Corrected Proof

2012-04-23

Background: The relationships between reaming parameters for glenoid-implant surface area and bone loss in total shoulder arthroplasty have not been well established. The hypotheses of this study are: (1) for large version corrections, a large reaming depth of 5 mm is not sufficient to obtain complete glenoid implant contact; (2) glenoid bone is removed in a linear proportion with reaming depth; and (3) initial reamer placement has no effect on glenoid bone removal.Methods: Ten computer models from computed tomography scans of patients with advanced osteoarthritis were created for computer-simulated reaming as performed during total shoulder arthroplasty. Reaming variables studied included reaming depth, reamer placement, and version correction. The resulting reamed glenoid surface area available for implantation and bone volume removed were calculated for each permutation.Results: Reamed surface area significantly increased with larger depths of reaming (P < .0001) and smaller version corrections (P < .0001). Bone volume removed and reaming depth had a strong quadratic relationship (r2 = 0.999). With off-center reamer placement, volume removed when deviating in the posterior direction was significantly greater than when deviating in the anterior, superior, or inferior direction (P < .05).Conclusion: Performing smaller version corrections allows for greater attainable implant-bone surface contact because increasing reaming depth results in small increases in conforming surface area but large losses in glenoid bone stock. Bone volume removed was most sensitive to off-center position errors in the posterior direction.

Arthroscopically assisted internal fixation of the symptomatic unstable os acromiale with absorbable screws - Corrected Proof

2012-04-23

Background: Symptomatic meso- type os acromiale is a common pathology with inconsistent outcomes of treatment with various surgical techniques. We report the outcome of a new technique for arthroscopic fusion of symptomatic os acromiale with absorbable screws.Materials and methods: The study included 8 shoulders in 8 patients with symptomatic meso- type os acromiale who were treated with the use of a new technique for arthroscopic fusion with absorbable screws. The mean age was 54 years (range, 38-67 years), and the mean time from onset of symptoms to surgery was 18 months (range, 9-25 months). No patients reported a specific traumatic event before the onset of symptoms, and all noted the insidious onset of pain with no precipitating event.Results: The average length of follow-up was 22 months (range, 12-36 month). The average Constant score improved from 49 points (range, 35-57 points) to 81 points (range, 75-86 points). The average satisfaction score improved from 4.5 of 10 (range, 2-6) to 8.5 of 10 (range 7-9). All patients made a good clinical recovery at 3 to 6 months after surgery. At the last follow-up, full radiographic union was observed in 6 patients, partial union in 1 patient, and persistent radiologic nonunion in 1 patient. Anterior bulging of the absorbable screws was noted in 2 patients, and the screws were trimmed 6 months after the first procedure.Conclusions: We have found that this new arthroscopic technique of fixation of os acromiale with absorbable screws provides promising clinical, cosmetic, and radiologic results with high patient satisfaction.

Tenocytes of chronic rotator cuff tendon tears can be stimulated by platelet-released growth factors - Corrected Proof

2012-04-23

Background: Bone-to-tendon healing after rotator cuff repairs is mainly impaired by poor tissue quality. The tenocytes of chronic rotator cuff tendon tears are not able to synthesize normal fibrocartilaginous extracellular matrix (ECM). We hypothesized that in the presence of platelet-released growth factors (PRGF), tenocytes from chronically retracted rotator cuff tendons proliferate and synthesize the appropriate ECM proteins.Materials and methods: Tenocytes from 8 patients with chronic rotator cuff tears were cultured for 4 weeks in 2 different media: standard medium (Iscove’s Modified Dulbecco’s Media + 10% fetal calf serum + 1% nonessential amino acids + 0.5 μg/mL ascorbic acid) and media with an additional 10% PRGF. Cell proliferation was assessed at 7, 14, 21, and 28 days. Messenger (m)RNA levels of collagens I, II, and X, decorin, biglycan, and aggrecan were analyzed using real time reverse-transcription polymerase chain reaction. Immunocytochemistry was also performed.Results: The proliferation rate of tenocytes was significantly higher at all time points when cultured with PRGF. At 21 days, the mRNA levels for collagens I, II, and X, decorin, aggrecan, and biglycan were significantly higher in the PRGF group. The mRNA data were confirmed at protein level by immunocytochemistry.Conclusions: PRGFs enhance tenocyte proliferation in vitro and promote synthesis of ECM to levels similar to those found with insertion of the normal human rotator cuffs.Clinical relevance: Biologic augmentation of repaired rotator cuffs with PRGF may enhance the properties of the repair tissue. However, further studies are needed to determine if application of PRGF remains safe and effective in long-term clinical studies.

Early failures with single clavicular transosseous coracoclavicular ligament reconstruction - Corrected Proof

2012-04-23

Introduction: Coracoclavicular (CC) ligament reconstruction remains a challenging procedure. The ideal reconstruction is biomechanically strong, allows direct visualization of passage around the coracoid, and is minimally invasive. Few published reports have evaluated arthroscopic techniques with a single clavicular tunnel and transcoracoid reconstruction. One such report noted early excellent results, but without specific outcome measures. This study reports the clinical and radiographic results of a minimally invasive, arthroscopically assisted technique of CC ligament reconstruction using a transcoracoid and single clavicular tunnel technique.Materials and methods: A retrospective review was performed of 10 consecutive repairs in 9 active duty patients who underwent CC ligament reconstruction with the GraftRope (Arthrex, Naples FL, USA). All reconstructions were performed according to the manufacturer’s technique by a single, fellowship-trained surgeon. Medical records and radiographs were evaluated for demographics, operative details, loss of reduction, and return to duty.Results: In 8 of 10 repairs (80%) intraoperative reduction was lost at an average of 7.0 weeks (range, 3-12 weeks). Four patients (40%) required revision. Subjective patient outcomes included 5 excellent/good results, 1 fair result, and 4 poor results. Tunnel widening was universally noted, and the failure mode in most patients appeared to be at the holding suture.Conclusion: This transcoracoid, single clavicular tunnel technique was not a reliable approach to CC ligament reconstruction. We noted a high percentage of radiographic redisplacement and clinical failure. This technique, in its current form, cannot be recommended to treat AC joint injuries in our population.

Acute surgical treatment of acromioclavicular dislocation type V with a hook plate: superiority to late reconstruction - Corrected Proof

Johan von Heideken, Helena Boström Windhamre, Viveka Une-Larsson, Anders Ekelund — 2012-04-23

Background: Outcomes for patients with acromioclavicular joint dislocation, Rockwood type V, treated with acute or delayed hook plate surgery were investigated.Materials and methods: Patients treated with a hook plate for acromioclavicular joint dislocation, Rockwood type V, were retrospectively evaluated 1 to 8 years after the injury. Of 41 patients, 37 were re-evaluated, 32 in person and 5 by telephone or letter. The acute surgery group comprised 22 patients operated on with a hook plate within 4 weeks after the injury. The delayed surgery group comprised 15 patients, with unacceptable pain or functional disability after a minimum of 4 months of conservative treatment, who were operated on with modified Weaver-Dunn procedure augmented with a hook plate. The evaluation was based on radiographs, registration of activity level, and shoulder function.Results: The median Constant Score was 91 for the acute surgery group and 85 for the delayed surgery group (P = .097). The acutely treated patients had better outcomes according to the median Shoulder Pain and Disability Index (SPADI; P = .006), shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH; P = .002), and Subjective Shoulder Value (P = .032). The acutely treated patients had less pain in their injured shoulder during rest (P = .014) and during movement (P = .005). There was a significant difference in subluxation between the groups in favor of the acute group, shown by weighted radiographs (P = .011), but no significant relation between subluxation on the weighted radiographs and the shoulder function according to Constant Score at follow-up (rs = .122, P = .619).Conclusions: Patients treated with acute surgery had a more satisfactory outcome than those with late surgery after failed conservative treatment.

Effect of different statistical methods on union or time to union in a published study about clavicular fractures - Corrected Proof

Valentin Neuhaus, David Ring — 2012-04-23

Background: Time to union is a suspect measure for comparing treatments given the absence of a consensus definition of union, the limited reliability of diagnostic tests, and inconsistency in evaluation times. The purpose of this study was to quantify the variations in union and time to union according to different statistical methods and different approaches to missing data.Materials and methods: Data from a published multicenter, randomized trial comparing operative and nonoperative treatment of clavicular fractures were reanalyzed. Two main types of missing data were encountered: (1) lost to follow-up or died before union and (2) missed appointment. We studied the effect of four statistical methods—comparison of means, comparison of medians, ϰ2, and Kaplan-Meier curves—for comparing union or time to union between cohorts for the following scenarios: strict intention-to-treat, intention-to-treat with exclusion of patients with less than 12 months of follow-up, as-treated analysis, and four different imputation methods for missing data.Results: Mean and median time to union varied up to 17%, but comparative statistics consistently demonstrated shorter time to union among operatively treated patients. There were significant differences in the odds ratio, ϰ2 values, and the number needed to treat (8%-62%) of union vs nonunion for the three principal analyses.Conclusion: Different strategies for handling missed evaluations seem to influence categoric results (eg, union or nonunion) more than continuous measures such as time to union.

A new technique for stabilizing adolescent posteriorly displaced physeal medial clavicular fractures - Corrected Proof

Thomas D. Tennent, Eyiyemi O. Pearse, Deborah M. Eastwood — 2012-04-20

Background: Adolescent posteriorly displaced physeal injuries of the medial clavicle are uncommon. Up to 50% of conservatively treated patients remain symptomatic, and late surgery is hazardous. Stability is rarely achieved with closed or open reduction alone, and internal fixation is usually required. Previously described options for fixation achieve stability of the medial clavicle by securing it to the intact epiphysis. Because the epiphyseal fragment is small, fixation is achieved using sutures or wires. This relies on the size and structural integrity of the medial fragment, which in our experience can be variable. We hypothesized that a novel technique of operative stabilization of these injuries, which does not require fixation to the epiphyseal fragment and uses no metalwork, is safe and effective in treating these injuries.Materials and methods: The operative technique involves suturing the medial clavicle to the anterior platysmal and periosteal layer using absorbable sutures passed through drill holes in the medial clavicle. Patients were assessed clinically an average of 9 months after surgery.Results: We treated 7 patients with this method. There were no intraoperative complications. All patients were pain-free and symptom-free and had a full range of movement at follow-up. All patients had returned to their preinjury level of sports.Conclusions: We recommend this technique for treating these uncommon injuries. It is simple, safe, and reproducible and it produces good results.

Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success - Corrected Proof

Eyal Amar, Eran Maman, Morsi Khashan, Ehud Kauffman, Ehud Rath, Ofir Chechik — 2012-04-20

Background: The shoulder is regarded as the most commonly dislocated major joint in the human body. Most dislocations can be reduced by simple methods in the emergency department, whereas others require more complicated approaches. We compared the efficacy, safety, pain, and duration of the reduction between the Milch technique and the Stimson technique in treating dislocations. We also identified factors that affected success rate.Methods: All enrolled patients were randomized to either the Milch technique or the Stimson technique for dislocated shoulder reduction.Results: The study cohort consisted of 60 patients (mean age, 43.9 years; age range, 18-88 years) who were randomly assigned to treatment by either the Stimson technique (n = 25) or the Milch technique (n = 35). Oral analgesics were available for both groups. The 2 groups were similar in demographics, patient characteristics, and pain levels. The first reduction attempt in the Milch and Stimson groups was successful in 82.8% and 28% of cases, respectively (P < .001), and the mean reduction time was 4.68 and 8.84 minutes, respectively (P = .007). The success rate was found to be affected by the reduction technique, the interval between dislocation occurrence and first reduction attempt, and the pain level on admittance.Conclusions: The success rate and time to achieve reduction without sedation were superior for the Milch technique compared with the Stimson technique. Early implementation of reduction measures and low pain levels at presentation favor successful reduction, which—in combination with oral pain medication—constitutes an acceptable and reasonable management alternative to reduction with sedation.

Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective - Corrected Proof

2012-04-20

Background: To examine the rates and predictors of deep periprosthetic infections after primary total shoulder arthroplasty (TSA).Methods: We used prospectively collected data on all primary TSA patients from 1976-2008 at Mayo Clinic Medical Center. We estimated survival free of deep periprosthetic infections after primary TSA using Kaplan-Meier survival. Univariate and multivariable Cox regression was used to assess the association of patient-related factors (age, gender, body mass index), comorbidity (Deyo-Charlson index), American Society of Anesthesiologists class, implant fixation, and underlying diagnosis with risk of infection.Results: A total of 2,207 patients, with a mean age of 65 years (SD, 12 years), 53% of whom were women, underwent 2,588 primary TSAs. Mean follow-up was 7 years (SD, 6 years), and the mean body mass index was 30 kg/m2 (SD, 6 kg/m2). The American Society of Anesthesiologists class was 1 or 2 in 61% of cases. Thirty-two confirmed deep periprosthetic infections occurred during follow-up. In earlier years, Staphylococcus predominated; in recent years, Propionibacterium acnes was almost as common. The 5-, 10-, and 20-year prosthetic infection–free rates were 99.3% (95% confidence interval [CI], 98.9-99.6), 98.5% (95% CI, 97.8-99.1), and 97.2% (95% CI, 96.0-98.4), respectively. On multivariable analysis, a male patient had a significantly higher risk of deep periprosthetic infection (hazard ratio, 2.67 [95% CI, 1.22-5.87]; P = .01) and older age was associated with lower risk (hazard ratio, 0.97 [95% CI, 0.95-1.00] per year; P = .05).Conclusions: The periprosthetic infection rate was low at 20-year follow-up. Male gender and younger age were significant risk factors for deep periprosthetic infections after TSA. Future studies should investigate whether differences in bone morphology, medical comorbidity, or other factors are underlying these associations.

The role of negative intraarticular pressure and the long head of biceps tendon on passive stability of the glenohumeral joint - Corrected Proof

Susan Alexander, Dominic F.L. Southgate, Anthony M.J. Bull, Andrew L. Wallace — 2012-04-20

Background: The purpose of this study was to determine the effect of intraarticular pressure and the long head of biceps (LHB) tendon on passive translations of the glenohumeral (GH) joint. Tenotomy or tenodesis of the LHB are common procedures but the consequences on shoulder stability are unclear.Methods: A novel shoulder laxity testing rig permitting six degrees of freedom of motion was used to test passive translations in anterior, posterior, superior, and inferior directions in 10 cadaveric shoulders. Specimens were tested in neutral rotation with 0°, 30°, 60°, or 90° of GH abduction in the scapular plane. Translation loads up to 30N were applied, and displacements measured in an intact joint, vented joint and with the biceps tendon loaded (20N).Results: The GH joint was most lax at 30° GH abduction. Venting of the joint increased translations in all positions and directions (mean ± standard error of the mean), the greatest difference was 12.5 (3.9) mm in the anterior–posterior direction and 7.5 (3.9) mm in the SI direction. Loading the LHB tendon with 20N decreased translations in all directions. The largest difference was observed in the anterior direction, 13.9 (2.8) mm (P < .0005) and inferior direction, 12.0 (2.8) mm (P < .0005).Conclusion: Negative intraarticular pressure and the LHB contribute significantly to overall passive stability of the GH joint. Surgical division or transfer of the LHB tendon may impact on joint stability and function.

Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures - Corrected Proof

2012-04-20

Purpose: This investigation used prospectively recorded intraoperative evaluation as the reference standard for distal humerus fracture type and characteristics, in order to measure the diagnostic performance characteristics of computed tomography (CT) and physical models. In secondary analyses, we assessed the reliability of classification.Methods: Thirty-five fractures were evaluated by the treating surgeon and first assistant on radiographs and 2-dimensional CT (2DCT) images first; a second time based on radiographs and 2- and 3-dimensional CT (3DCT) images; a third time based on 2- and 3DCT as well as 3D physical models; and a fourth time based on intraoperative visualization of the fracture characteristics. The intraoperative evaluation of the attending surgeon was used as the reference standard.Results: The addition of 3DCT and the 3D models to 2DCT and radiographs led to significant improvements in sensitivity, but not specificity, in the diagnosis and proposed treatment, and improved the interobserver agreement with respect to specific fracture characteristics but not classification.Conclusion: Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics.

Fractures of the coronoid: morphology based upon computer tomography scanning - Corrected Proof

2012-04-19

Hypothesis/Background: Coronoid fractures have traditionally been described by the Regan-Morrey classification system, based upon lateral plain film radiographs. However, use of computer tomography (CT) scans to determine fracture morphology, define associated injuries, and make treatment plans is now commonplace. In addition, it is increasingly recognized that classification systems based upon plain film imaging studies may not be adequate to describe complex fracture patterns. The purpose of the present investigation was to review CT scans obtained for elbow trauma to describe coronoid fracture morphology and determine inter- and intra-observer reliability.Methods: CT scans performed for elbow trauma over a 2-year period were examined to identify coronoid fractures, and recurring patterns were sought. After patterns were identified, the scans were reviewed by 3 observers to determine inter- and intra-observer reliability.Results: Of 373 CT scans, 52 identified coronoid fractures were appropriate for review. Five common patterns were identified, including a tip type, mid-transverse type, basal type, anteromedial oblique fractures, and an anterolateral oblique type fracture that has not been well described previously. Inter- and intra-observer reliability ranged from good to very good in this series.Discussion/Conclusion: In this series, we describe anatomic patterns by which coronoid fractures break. Five common patterns were noted: a “tip” type fracture seen in 29% of the cases; a “mid-transverse” type fracture (24%); a “basal” type fracture (23); and 2 “oblique” type fracture patterns (24%), including an “anteromedial” type fracture (17%) and an “anterolateral” type (7%). There was a high rate of intra- and inter-observer reliability between and within 3 observers.

Treatment of scapular winging with modified Eden-Lange procedure in patient with pre-existing glenohumeral instability - Corrected Proof

John G. Skedros, Alex N. Knight — 2012-04-09

Primary scapular winging typically results from palsies of the serratus anterior, trapezius, and rhomboid muscles, which are caused by injury to the long thoracic nerve, spinal accessory nerve, and dorsal scapular nerve, respectively. The Eden-Lange procedure has become the surgical treatment of choice for scapular winging from trapezius palsy because other surgical procedures have high failure rates. In this procedure the levator scapulae muscle is transferred laterally to the scapular spine, and the rhomboid minor and major are both transferred laterally to the infraspinous fossa. The modification of this procedure by Bigliani and coworkers includes transfer of the levator scapulae muscle laterally to the scapular spine and lateral transfer of the rhomboid minor and major to the supraspinous and infraspinous fossae, respectively. The modified and standard Eden-Lange procedures have been shown to be successful in eliminating scapular winging by restoring the major actions of the trapezius muscle.

The upper band of the subscapularis tendon in the rat has altered mechanical and histologic properties - Corrected Proof

Stephen J. Thomas, Kristin S. Miller, Louis J. Soslowsky — 2012-04-09

Background: The subscapularis is an important mover and stabilizer of the glenohumeral joint. Since the advent of shoulder arthroscopy, partial tears are found in 43% of rotator cuff patients. While partial tears to the upper band occur more commonly, little is known about the structure and mechanical behavior of the individual bands. Therefore, the objective of this study was to measure tensile mechanical properties, corresponding collagen fiber alignment, and histology in the upper and lower bands of the rat subscapularis tendon.Materials and methods: Thirty adult Sprague-Dawley rats were euthanized and subscapularis tendons dissected out for mechanical organization (n = 24) and histologic assessment (n = 6). Collagen organization was measured with a custom device during mechanical testing.Results: Linear-region modulus at the insertion site was significantly lower in the upper band compared to the lower band, while no differences were found at the midsubstance location. The upper band was found to be significantly less aligned and demonstrated a more rounded cell shape than the lower band at the insertion site.Discussion: This study demonstrated that the 2 bands of the subscapularis tendon have differential mechanical, organizational, and histological properties, which suggests a functional deficit exists to the upper band of the subscapularis and may be contributing to the prevalence of partial subscapularis tears.Conclusions: Clinicians should be aware that the upper band of the subscapularis tendon may be at higher risk of developing tears, based on decreased mechanical properties and a more disorganized collagen fiber distribution.

Fifty most cited articles in orthopedic shoulder surgery - Corrected Proof

Surena Namdari, Keith Baldwin, Kevin Kovatch, G. Russell Huffman, David Glaser — 2012-04-09

Background: The number of times an article has been cited has been used as a marker of its influence in a medical specialty. The purpose of this study was to determine the 50 most cited articles in shoulder surgery and their characteristics.Methods: Science Citation Index Expanded was searched for citations of articles published in any of the 61 journals in the category “Orthopedics.” Each of the journals was searched to determine the 50 most often cited articles specific to shoulder surgery. The following characteristics were determined for each article: authors, year of publication, source journal, geographic origin, article type, and level of evidence for clinical articles. Citation density (total number of citations/years since publication) was also determined.Results: The number of citations ranged from 1211 to 192. The 50 most often cited articles were published in 8 journals. The majority of the articles (42) were clinical, with the remaining representing some type of basic science research. The most common level of evidence was IV (23). The mean number of citations for methodologic articles (437 citations per article) was greater than that for non-methodologic articles (301 citations per article) (P = .034).Conclusions: Articles that introduced instruments for outcome evaluation or that introduced classification systems (methodologic) were highly cited regardless of the date of publication. The top 50 list presented provides residency and fellowship directors with a group of “classic” articles in the subspecialty of orthopedic shoulder surgery that can be included in reading curriculums for their trainees.

The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers - Corrected Proof

2012-04-05

Background: Injections of the acromioclavicular joint (ACJ) are performed routinely in patients with ACJ arthritis, both diagnostically and therapeutically. The aim of this prospective controlled study was to estimate the frequency of successful intra-articular ACJ injections with the aid of sonographic guidance versus non-guided ACJ injections.Materials and methods: A total of 80 cadaveric ACJs were injected with a solution containing methylene blue and subsequently dissected to distinguish intra- from peri-articular injections. In 40 cases the joint was punctured with sonographic guidance, whereas 40 joints were injected in the control group without the aid of ultrasound.Results: The rate of successful intra-articular ACJ injection was 90% (36 of 40) in the guided group and 70% (28 of 40) in the non-guided group. Ultrasound was significantly more accurate for correct intra-articular needle placement (P = .025).Discussion: The use of ultrasound significantly improves the accuracy of ACJ injection.

Glenohumeral joint penetration with a 21-gauge standard needle - Corrected Proof

Aureola Tong, Richard Harding, Geoff Graham — 2012-03-29

Background: This study assessed whether a standard 21-gauge needle (length, 38.1 mm [1.5 inches]) is more likely to penetrate the glenohumeral joint through an anterior or a posterior approach.Methods: Seventy-nine patients underwent an arthroscopic procedure on the glenohumeral joint. The depth from the skin to the joint capsule was compared between the posterior approach (10 mm medial and inferior to the posterolateral tip of the acromion) and the anterior approach (direct visualization through the rotator interval). Each approach was measured twice and the mean used. The data were analyzed using a 2-sided paired t test.Results: The anterior approach was shorter than the posterior approach in all patients (P < .001). This was less than the length of a standard needle in 98.7% of patients. The mean skin-to-joint capsule depth was 43.5 mm (range, 24-58 mm) with the posterior approach and 27.1 mm (range, 12.5-40 mm) with the anterior approach. On average, the posterior approach was 16.3 mm deeper (range, 0.5-31.5 mm) than the anterior approach.Conclusions: Injections through the anterior approach are more likely to penetrate the glenohumeral joint than through the posterior approach if a standard needle is used.

Surgeon perceptions and patient outcomes regarding proximal ulna fixation: a multicenter experience - Corrected Proof

2012-03-26

Background: Our objective was to determine surgeon- and patient-based perceptions concerning proximal ulna fixation, including rates of implant removal and overall satisfaction.Methods: Orthopedic surgeons were surveyed about surgical experience managing proximal ulna fractures and their perception regarding implant removal/revision. A retrospective chart review identified all patients who underwent fixation for proximal ulna fractures and osteotomies between January 2004 and December 2008.Results: In total, 583 surgeons responded to the survey (80%). Of these, 67% believed that their implant removal rate was the same as other surgeons whereas 31% believed that their rate was lower. Seventy-one percent believed that patients required hardware removal less than 30% of the time. Ninety-eight percent believed that they were the same surgeons to remove the implant. In total, 138 consecutive patients were surveyed about their proximal ulna implant. Plating was performed in 80 (58%), and tension banding was performed in 55 (40%). The overall rate of implant removal was 64.5% (89 of 138) at 18.8 months. A second surgeon performed the removal in 68 patients (76%). Of the 49 patients without implant removal, 11 (22%) reported satisfaction with the implant and 19 (39%) reported a functional impairment because of the implant. If guaranteed a safe surgery, 36 (73%) would have the implant removed.Conclusion: Surgeons underestimate the rates of proximal ulna implant removal and patient dissatisfaction. Because 76% of the implant removals were performed by a second surgeon, in sharp contrast to the surgeon-perceived rate of 2%, we challenge surgeons to become more aware of this problem in their practices.

Effect of stem length on prosthetic radial head micromotion - Corrected Proof

Dave R. Shukla, James S. Fitzsimmons, Kai-Nan An, Shawn W. O’Driscoll — 2012-03-26

Background: Osteointegration of press-fit radial head implants is achieved by limiting micromotion between the stem and bone. Aspects of stem design that contribute to the enhancement of initial stability (ie, stem diameter and surface coating) have been investigated. The importance of total prosthesis length and level of the neck cut has not been examined.Methods: Cadaveric radii were implanted with cementless, porous-coated radial head stems. We resected 10, 12, 15, 20, and 25 mm of radial neck in each specimen. Stem-bone micromotion was measured after each cut. Values were expressed in terms of quotients (cantilever quotient).Results: A threshold effect was observed at 15 mm of neck resection (cantilever quotient, 0.4), with a significant increase in micromotion observed between 12 mm (40 ± 10 μm) and 15 mm (80 ± 25 μm). A cantilever quotient of 0.35 or less predicted implant stability, whereas implants with a cantilever quotient of 0.6 or more were unstable. In between, the stems were “at risk” of instability.Conclusion: Initial stem stability of a porous-coated, cementless radial head implant is dependent on length of the implant stem within bone and the level of the cut (amount of bone resected). Stability may be compromised by an implant with a combined head and neck length that is too long compared with the stem length within the canal. We found a critical ratio of exposed prosthesis to total implant length (cantilever quotient of 0.4), which puts the prosthesis at risk of inadequate initial stability. These data carry important implications for implant design and use.

Comparison of ultrasound-guided versus blind glenohumeral injections: a cadaveric study - Corrected Proof

2012-03-26

Background: Intra-articular glenohumeral (GH) injections are important for diagnostic and therapeutic purposes. It has been suggested that ultrasound guided injections are more accurate than blind or freehand injections. This study assessed the accuracy of ultrasound-guided GH injections compared with freehand injections in fresh cadavers.Methods: The study used 80 shoulder specimens from fresh cadavers. Ultrasound guidance was used to inject radiopaque contrast in 40 shoulders, and freehand technique was used in the remaining 40. All injections were performed by 2 surgeons (A and B) through a posterior approach. After the injections, radiographs were obtained of the specimens to assess the accuracy of the injections.Results: Sixty-six of 80 (82.5%) injections were accurately administered into the GH joint. Ultrasound-guided injections were accurate in 37 of 40 specimens (92.5%) compared with freehand injections, which were accurate in only 29 of 40 specimens (72.5%; P = .02). Both surgeons independently had higher accuracy using ultrasound-guidance compared with the freehand technique (surgeon A: 90% vs 65%, P = 0.058; surgeon B: 95% vs 80%, P = 0.15). The average time for injections was 52 seconds by the freehand technique and 166 seconds using ultrasound guidance (P < 0.001).Conclusions: The data from this cadaveric study suggest that ultrasound-guided injections are more accurate at reaching the GH joint than freehand injections. The ultrasound-guided injections took substantially longer to administer. Once familiar with the technique, surgeons can expect improved accuracy and efficacy of GH joint injections using ultrasound guidance in the clinical setting.

Revision total shoulder arthroplasty for painful glenoid arthrosis after humeral head replacement: the nontraumatic shoulder - Corrected Proof

2012-03-26

Background: Patients treated with humeral head replacement (HHR) may require revision to total shoulder arthroplasty (TSA) due to glenoid arthrosis. This study characterizes the outcomes of revision TSA in patients who initially underwent HHR for nontraumatic glenohumeral arthritis.Methods: From 1982 to 2005, 68 shoulders underwent revision TSA for glenoid arthrosis. The initial HHR was performed for non–fracture-related arthritis. Revisions were grouped according to complexity for analysis. Stem revision and soft tissue reconstruction were assessed in relation to outcome.Results: Pain scores decreased from 4.4 to 2.8, abduction increased from 85° to 116°, external rotation increased from 36° to 48°, and internal rotation remained unchanged. Survivorship free of repeat revision was 95.6%, 84.1%, and 72.9% at 1, 5, and 10 years. The Neer rating yielded 20 excellent, 10 satisfactory, and 38 unsatisfactory outcomes. No differences in motion, survivorship, or the Neer rating occurred between groups by procedure complexity. There was, however, less reduction in pain for the group requiring a humeral stem revision. Of the 9 shoulders with postoperative instability, 7 had compromised soft tissues preoperatively.Conclusions: Revision TSA after HHR results in decreased pain and increased motion. Result ratings, however, are quite variable and, in many cases, unsatisfactory. Stratification of the procedures according to complexity does not demonstrate differences in motion, satisfaction, or survivorship. Stem revision, however, results in reduced pain score improvement. Coexisting instability associated with subscapularis and anterior shoulder capsule damage may not be correctable using an unconstrained shoulder arthroplasty.

Results of anatomic nonconstrained prosthesis in primary osteoarthritis with biconcave glenoid - Corrected Proof

Gilles Walch, Claudio Moraga, Allan Young, Juan Castellanos-Rosas — 2012-03-26

Background: Biconcave glenoids in primary osteoarthritis represent a challenge because of the associated static posterior instability of the humeral head and secondary posterior glenoid erosion. This study evaluated the influence of different preoperative radiographic measurements on the outcome of total shoulder arthroplasty (TSA), particularly regarding the development of complications.Materials and methods: We retrospectively evaluated 92 anatomic TSAs performed in 75 patients with primary osteoarthritis and a biconcave glenoid. All patients underwent preoperative imaging with an axial computed tomography arthrogram. Measurements were taken for posterior bone erosion depth and ratio as well as humeral head subluxation. Clinical outcomes were evaluated with the Constant score.Results: At an average follow up of 77 months (range, 14-180 months), 15 revisions (16.3%) were performed for glenoid loosening (6.5%), posterior instability (5.5%), or soft tissue problems (4.3%). At the final follow-up, the mean Constant score improved significantly from 32.4 to 68.8 points (P = .0001). Subjectively, 66.3% of patients were very satisfied or satisfied. Glenoid loosening was observed in 20.6% and was significantly associated with posterior bone erosion in depth (P = .005) and wear ratio (P = .02), humeral head subluxation (P = .01), and neoglenoid (P = .002) and intermediate glenoid retroversion (P = .001). Dislocation was correlated only with neoglenoid retroversion (P = .01).Conclusions: Performing TSA in patients with osteoarthritis and biconcave glenoids resulted in acceptable clinical outcomes but a very high rate of complications. We found that the preoperative measurement of the neoglenoid retroversion was best for predicting postoperative complications in terms of glenoid loosening and dislocation.

Do the rotator cuff tendons of young athletic subjects hypertrophy in response to increased loading demands? - Corrected Proof

Charles Milgrom, Daniel S. Moran, Ori Safran, Aharon S. Finsestone — 2012-03-26

Background: The rotator cuff is composed of muscle and tendon units. Although muscle has been shown to adapt to mechanical loads, the response of human tendon is not well defined. We hypothesized that increased loading demands on the rotator cuff of young trainees would cause an adaptive muscle response but not an adaptive hypertrophic tendon response.Methods: The hypertrophic response of the rotator cuff tendon, shoulder strength, aerobic fitness, and the lean body weight of 70 young male recruits were studied before and after a 1-year course of elite infantry training. Shoulder strength was assessed by the maximum number of pull-ups done and the rotator cuff thickness by ultrasound measurement of the supraspinatus thickness. Aerobic physical fitness was assessed by maximum oxygen consumption (Vo2 max). Lean body weight was measured by skin-fold thickness.Results: The mean number of pull-ups done increased from 17.5 to 21.7 (P = .01), but the supraspinatus thickness at the beginning of training (6.1 mm) was unchanged at the end of the training. Vo2 max increased from 57 to 64 mL/kg/min (P = .0001). Lean body weight increased from 58.3 to 64.7 kg (P = .0001).Conclusions: As a result of increased loading, the strength of the rotator cuff muscles of young trainees increased, but by the parameter of hypertrophy, no evidence was found of a parallel adaptive response of the rotator cuff tendon.