Journal of Shoulder and Elbow Surgery - Articles in Press

Management of chronic shoulder infections utilizing a fixed Articulating antibiotic-loaded spacer - Corrected Proof

Ian A. Stine, Brian Lee, Charalampos G. Zalavras, George Hatch, John M. Itamura — 2010-02-05

Background: Literature on management of chronic shoulder infections is limited. The purpose of this study was to examine the efficacy of a standardized protocol for the management of chronic shoulder infections, including periprosthetic infections, utilizing an articulating antibiotic-loaded spacer.Material and methods: Thirty patients with chronic shoulder infections (4 primary and 26 postoperative) were treated with aggressive debridement, implantation of an antibiotic-loaded articulating spacer, and systemic antibiotics. Twenty-seven patients (90%) were compromised hosts. Eighteen patients (group I) elected to keep the spacer but three patients later underwent reimplantation, thus fifteen patients (group IA) were using the spacer as a prosthesis at their latest follow-up of 2.4 years. Twelve patients (group II, follow-up of 2.3 years) underwent reimplantation of a prosthesis.Results: Eradication of infection was accomplished in all 30 patients. Group IA patients had a Disability of Arm Shoulder and Hand (DASH) score of 50, Simple Shoulder Test (SST) score of 5, forward flexion of 73°, abduction of 71°, and external rotation of 29°. Group II patients had a DASH score of 58, SST score of 5, forward flexion of 78°, abduction of 83°, and external rotation of 19°. The differences between these 2 groups were not significant.Discussion: Chronic shoulder infections can be successfully treated with a protocol of aggressive debridement, antibiotic-loaded articulating spacer, and systemic antibiotics. Prolonged implantation of an articulating spacer may be a viable option in select low-demand patients with comorbidities.Level of Evidence: Level IV; Retrospective Case Series, Treatment Study.

Reliability of the glenoid plane - Corrected Proof

Lieven F. De Wilde, T. Verstraeten, W. Speeckaert, A. Karelse — 2010-02-05

Hypothesis: The purpose of this study was to investigate the 3-dimensional (3-D) orientation of the glenoid and scapular planes. Different definitions of the glenoid plane were used and different planes measured, and we hypothesed that the 3-D plane with the least variation would be best to define the most reliable glenoid plane.Methods: We studied 150 CT scans from nonpathological shoulders from patients between 18 and 80. The scapular plane and 5 different glenoid planes were determined: inferior, anterior, posterior, superior, and neutral. All plane versions and inclination angles were measured. Because all examinations were done in a standardized position to the coronal, sagittal, and transverse planes of the body, the scapular plane could be defined versus the coronal, sagittal, and transverse planes of the body.Results: The version (mean, 3.76) of the inferior glenoid plane showed a significantly lower standard deviation than the version of the anterior (P < .001), posterior (P=.001), and superior (P=.001) glenoid plane (ANOVA). For inclination all planes have a similar variance. The scapular plane was different between gender (P=.022) and correlated with age.Conclusion: This study showed that the retroversion of the inferior glenoid is reasonably constant. The osseous anthropometry of the inferior glenoid can offer a reproducible point of reference to be used in prosthetic surgery of the shoulder.Level of Evidence: Level II, Basic Science Study, Anatomical Survey.

Acute ischemia of the hand seven months after tension-band wiring of the olecranon - Corrected Proof

J.C. Rompen, G.A. Vos, C.C.P.M. Verheyen — 2010-02-05

Surgical treatment of complex articular distal humerus fractures is a challenge for the trauma surgeon. Different surgical approaches have been described. Exposure of the articular surface of the distal humerus can best be achieved with olecranon osteotomy, most commonly repaired with tension-band wiring. This technique is regarded as safe and yields satisfactory clinical results. We describe a patient in whom an acute ischemia of the ipsilateral hand developed, caused by prominent K-wires, 7 months after surgical treatment of a comminuted distal humeral fracture.

Image-based navigation improves the positioning of the humeral component in total elbow arthroplasty - Corrected Proof

Colin P. McDonald, James A. Johnson, Terry M. Peters, Graham J.W. King — 2010-02-05

Hypothesis: Implant alignment in total elbow arthroplasty (TEA) is a challenging and error-prone process using conventional techniques. Identification of the flexion-extension (FE) axis is further complicated for situations of bone loss. This study evaluated the accuracy of humeral component alignment in TEA. We hypothesized that an image-based navigation system would improve humeral component positioning, with navigational errors less than or approaching 2.0 mm and 2.0°.Materials and methods: Implantation of a modified commercial TEA humeral component was performed with and without navigation on 11 cadaveric distal humeri. Navigated alignment was based on positioning the humeral component with the aid of a computed tomography (CT)-based preoperative plan registered to landmarks on the distal humerus. Alignment was performed under 2 scenarios of bone quality: (1) an intact distal humerus, and (2) a distal humerus without articular landmarks.Results: Navigation significantly improved implant alignment accuracy (P < .001). Navigated implant alignment was 1.2 ± 0.3 mm in translation and 1.3° ± 0.3° in rotation for the intact scenario. For the bone loss scenario, navigated alignment error was 1.1 ± 0.5 mm and 2.0° ± 1.3°. Non-navigated alignment was 3.1 ± 1.3 mm and 5.0° ± 3.8° for the intact scenario and 3.0 ± 1.6 mm and 12.2° ± 3.3° for the bone loss scenario.Discussion: Image-based navigation improves the accuracy and reproducibility of humeral component placement in TEA. Implant alignment errors for the navigated alignments were below the target of 2.0 degrees and 2 mm that is considered standard for most navigation systems. Non-navigated implant alignment error was significantly greater for the bone loss scenario compared with the intact scenario.Conclusions: Implant malalignment may increase the likelihood of early implant wear, instability, and loosening. Improved implant positioning will likely lead to fewer complications and greater prosthesis longevity.Level of evidence: Basic Science Study.

Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: Mini-open versus all-arthroscopic - Corrected Proof

R. Sean Churchill, Jugal K. Ghorai — 2010-02-05

Background: The objective of this study was to determine mean cost and operative time differences between mini-open and all-arthroscopic rotator cuff repair techniques at surgical centers of low, intermediate, and high annual rotator cuff repair volume.Methods: The 2006 New York State Ambulatory Surgery Database (NY-SASD) was utilized. It represents 100% of all outpatient procedures performed in hospital-affiliated and freestanding surgical centers, containing 10,658,923 patients for 2006 alone. Only patients who had an arthroscopic acromioplasty and either open or arthroscopic rotator cuff repair were included, leaving 5,224 patients for the study. These were divided into 2 groups: the mini-open group (1,334) and the all-arthroscopic group (3,890). Surgical center volume data were divided into 3 groups: low volume (<75 rotator cuff repairs per year), intermediate volume (75-199 rotator cuff repairs per year), and high volume (200+ rotator cuff repairs per year).Results: Patient age and gender were normally distributed within the 2 groups with no significant differences between them (P = .82 and P = .31, respectively). Operative time was significantly shorter in the mini-open group (103 minutes) compared to the all-arthroscopic group (113 minutes), P < .00001. Surgical charges were also significantly less in the mini-open group ($7,841) compared to the all-arthroscopic group ($8,985), P < .00001. Regardless of the repair method, high volume surgical centers were significantly more expensive when compared to low and intermediate volume centers, P < .00001.Conclusion: The mini-open rotator cuff repair technique requires significantly less operative time and is significantly less expensive than the all-arthroscopic repair. Regardless of the repair technique, high volume surgical centers cost significantly more than low and intermediate volume surgical centers.Level of evidence: Level III, Retrospective Case-Control Study, Treatment Study.

Can shoulder arthroplasty restore the range of motion in activities of daily living? A prospective 3D video motion analysis study - Corrected Proof

2010-02-05

Hypothesis: There are limited data how total shoulder arthroplasty (TSA) improves shoulder function during activities of daily living (ADL). The hypothesis of this study was that the range of motion (ROM) in ADL gets back to normal after TSA .Materials and method: We examined 13 patients before they received TSA for osteoarthritis and 6 months postoperatively with a 3D motion video analysis during 3 ADL and compared them with a control group without any shoulder pathology.Result: Comparing the TSA status preoperatively and postoperatively resulted in a significant increase of the mean values of the ROMs in the ADL in all planes (P < .05). When the postoperative ROM was compared with the controls, TSA was able to restore the ROM in all planes except for abduction in 2 of 3 ADL. The patients were not able to use their maximum active abduction during the course of the ADL.Discussion: TSA improves the ROM in ADL, but it cannot return completely to normal in abduction after 6 months.Conclusion: This is not related to limitations of active or passive ROM but may be due to impaired proprioception or pathologic movement patterns, or both.Level of evidence: Level III, Case-Control Study, Treatment Study.

Effect of anterior supraspinatus tendon partial-thickness tears on infraspinatus tendon strain through a range of joint rotation angles - Corrected Proof

Nelly Andarawis-Puri, Andrew F. Kuntz, Soung-Yon Kim, Louis J. Soslowsky — 2010-01-18

Background: Rotator cuff tears are common shoulder problems whose propagation is difficult to predict because of the structural and mechanical inhomogeneity of the supraspinatus tendon. We have previously shown that the supraspinatus and infraspinatus tendons interact mechanically when the supraspinatus tendon is intact or exhibits a full-thickness tear, so that an increase in supraspinatus tendon strain is paralleled by an increase in infraspinatus tendon strain. Such interaction is critical and suggests that an increase in infraspinatus tendon strain that accompanies an increase in supraspinatus tendon strain may shield the supraspinatus tendon from further injury, but increase the risk of injury to the infraspinatus tendon. In this study, the mechanical interactions between the supraspinatus and infraspinatus tendons were evaluated for the commonly occurring supraspinatus tendon partial-thickness tears through a range of rotation angles.Methods: For each joint rotation and supraspinatus tendon tear size evaluated, the supraspinatus tendon was loaded, and images corresponding to 5N, 30N, 60N, and 90N of supraspinatus tendon load were isolated for the speckle painted supraspinatus and infraspinatus tendons. A region of interest outlining the insertion site was isolated and displacements between the 5N loaded image and each of the others were measured, from which normalized average principal strains were quantified in both tendons.Results: The observed effect on infraspinatus tendon strain paralleled that observed on strain in the supraspinatus tendon. Introducing a supraspinatus tendon partial-thickness tear and increasing load caused an increase in normalized average maximum and a decrease in normalized average minimum principal strain in the infraspinatus tendon. Increasing rotation angle from internal to external rotation caused a general decrease in normalized average maximum and increase in normalized average minimum principal strain in both tendons.Conclusion: The supraspinatus and infraspinatus tendons mechanically interact for the intact and partially torn supraspinatus tendons for neutral and rotated glenohumeral joint.Level of Evidence: Basic Science Study.

Reversed arthroscopic subacromial decompression for symptomatic irreparable rotator cuff tears: Mid-term follow-up results in 34 shoulders - Corrected Proof

2010-01-08

Background: In the elderly, there is no guideline for the treatment of irreparable rotator cuff lesions. The results of open or arthroscopic repair are variable. We hypothesized that the use of a reversed arthroscopic subacromial decompression (RASD) would yield comparable results.Material and methods: Between January 2004 and December 2006, thirty-eight patients underwent a RASD for irreparable cuff tears in 39 shoulders. The surgical procedure consisted of a tenotomy of the long head of the biceps tendon, a debridement of the torn rotator cuff and a tuberoplasty, without violation of the coracoacromial arch and the acromion.Results: Thirty-three patients (age 69.9 ± 7.3 years) were available for clinical and radiological evaluation of 34 shoulders (male/female ratio: 11/22), at a mean follow-up of 38 months (range: 21 months–52 months). Two of 33 patients had required revision surgery, and were excluded from further statistical analysis. In the remaining 31 patients (32 shoulders), the modified Constant-Murley score (CMS) improved from 34.9% ± 11.6 to 84.0% ± 11.6 (p < 0.0001). The preoperative mobility did not correlate with the final result. Preoperative pain was found to correlate negatively to the modified CMS at follow-up (p= 0.0038). Although the acromiohumeral height decreased with 2.58 mm ± 1.68 and the severity of glenohumeral osteoarthritis increased with one grade (Samilson-Prieto classification), there was no correlation with the functional outcome.Conclusion: We conclude that for irreparable rotator cuff tears in the elderly, excellent mid-term results can be achieved with a RASD.Level of evidence: Level IV, Retrospective Case Series, Treatment Study.

Outcome of total elbow replacement for rheumatoid arthritis: Single surgeon's series with Souter-Strathclyde and Coonrad-Morrey prosthesis - Corrected Proof

Narayana Prasad, Colin Dent — 2010-01-08

Background: The reported outcome of total elbow replacement is inferior to hip and knee arthroplasty, and there might be an element of institutional bias.Methods: We analyzed the outcome of Souter and Coonrad-Morrey total elbow prosthesis in rheumatoid elbow performed by a single surgeon from a center independent from standpoint of being involved in the designing or manufacturing of the implant.Results: We had 44 Souter elbows with a mean follow-up of 108 months and 55 Coonrad-Morrey elbows with mean follow-up of 60 months. The Mayo Elbow Performance Score was comparable in both the groups with similar subjective satisfaction. Souter elbow showed a survivorship of 92.9% at 5 years and 76% at 10 years, with aseptic loosening rate of 18% and instability of 9% as main reasons for the failure. The Coonrad-Morrey elbow shows 100% survival at mean follow-up of 5 years in our series.Conclusion: We find high rate of instability and loosening of Souter prosthesis with an inferior 5-year survival compared to Coonrad-Morrey prosthesis.Level of evidence: Level III, Case-Control Series, Treatment Study.

Suprascapular neuropathy secondary to reverse shoulder arthroplasty: A case report - Corrected Proof

Jianhua Wang, Anshu Singh, Laurence Higgins, Jon Warner — 2010-01-08

Suprascapular neuropathy (SSN) is a relatively rare cause of shoulder pain that is usually made as a diagnosis of exclusion. Reported causes of SSN include compression from adjacent ganglia, abnormal morphology of the suprascapular notch, neuritis, direct trauma or traction injury, massive rotator cuff tear, and iatrogenic injury. We present a case of SSN as a consequence of errant superior screw placement during revision reverse shoulder arthroplasty.

Reverse glenoid component fixation: Is a posterior screw necessary? - Corrected Proof

2010-01-08

Background: Reverse shoulder arthroplasty has become more prevalent for the treatment of complex shoulder issues. Prosthetic designs vary in both the number and orientation of screws recommended for securing the glenoid base plate. This study examined the contribution of the posterior glenoid screw for stabilizing the glenosphere by comparing constructs with no posterior screw, a standard posterior screw directed into the glenoid neck, and a long posterior screw (LPS) into the scapular spine.Material and methods: The Tornier RTSA glenoid implant was fixed into 2 groups of matched cadaveric scapulae. In both groups, the controls were fixed with a standard posterior screw (SPS). Matching scapulae had a screw configuration that omitted the posterior screw (NPS) in group I or utilized an LPS in group II. Specimens were tested using a “rocking-horse” protocol. During cyclic loading (50,000 cycles), the vertical displacement of the glenoid component was monitored using a digital caliper.Results: In group I, NPS constructs demonstrated a significantly higher mean rate of loosening than SPS constructs. In group II, the LPS constructs demonstrated lower loosening rates than SPS constructs. Mean initial displacements were greater for NPS than SPS in group I and similar for SPS and LPS in group IIDiscussion: The posterior glenoid screw contributes significantly to stability of the reverse glenoid base plate. If an SPS does not obtain good purchase into the scapula, glenoid component fixation will be enhanced by the addition of an LPS into the scapular spine.Level of evidence: Basic Science Study

Contribution of the supraspinatus to the external rotator lag sign: Kinematic and electromyographic pattern in an in vivo model - Corrected Proof

2010-01-08

Hypothesis: The external rotation lag sign (ERLS) is a test designed to assess the integrity of the supraspinatus (SSP) and infraspinatus tendons. This study intends to determine the electromyographic pattern of shoulder girdle muscles during a series of ERLS tasks conducted at full adduction and 20° of elevation to figure out the better way to perform the test. The second aim is to assess the final contribution of the SSP to the ERLS by measuring the amount of lag after an SSP block induced by botulinum toxin.Materials and methods: Ten subjects with healthy shoulders were examined by a series of five ERLS trials at full adduction and 20° of elevation in the scapular plane. Surface and intramuscular electromyographic activity of the shoulder girdle muscles was recorded and normalized against either the mean activity of all the muscles or the peak activity. The lag was simultaneously measured by an infrared optoelectronic system before and after the selective block of the SSP muscle.Results: The SSP contributed 20% of the electrical activities during the ERLS, which was found to be significantly greater than the contributions of the other shoulder girdle muscles, except for the infraspinatus. The selective block of the SSP caused a lag of 4° in all 10 shoulders at 20° but no increase in lag at 0° of elevation.Conclusions: The ERLS is potentially able to detect an isolated SSP tear if the test is performed correctly (20° of abduction). The deltoid and biceps muscles are almost silent during the test, limiting confounding factors.Level of evidence: Basic Science Study, Electrodiagnostic Study.

Insertional anatomy of the triceps brachii tendon - Corrected Proof

Jay D. Keener, Dara Chafik, H. Mike Kim, Leesa M. Galatz, Ken Yamaguchi — 2010-01-08

Hypothesis: Triceps tendon anatomy is important for surgical approaches to the elbow and tendon repair. The purpose of this study is to describe both the qualitative and quantitative anatomy of the triceps brachii tendon insertion.Materials and methods: Thirty-six elbows were dissected from twenty-three cadavers. Dimensions of the triceps tendon proper, lateral triceps expansion, and tendon insertion were measured. The central triceps tendon morphology was described.Results: All specimens showed a distinct lateral tendon expansion continuous with the anconeus fascia (mean width, 16.8 mm). The mean width of the proper triceps tendon was 23.7 mm. The mean maximum olecranon width was 26.9 mm. The ratio of the triceps tendon width to the olecranon width averaged 0.88. The mean thickness of the central tendon insertion was 6.8 mm. The medial triceps tendon showed a distinct, rolled medial edge and an insertion consistently confluent with the central tendon. The triceps footprint insertion was dome shaped. The mean insertional width and length of the tendon proper were 20.9 mm and 13.4 mm, respectively. The mean distance from the olecranon tip to the tendon was 14.8 mm. The tendon width, thickness, and insertional dimensions correlated with the olecranon width.Conclusions: The lateral triceps expansion is a consistent anatomic finding with a width that is approximately 70% of the width of the central tendon. The triceps insertion has a broad width and narrow thickness that expands distally and correlates with the size of the olecranon. Knowledge of this anatomy will help the surgeon optimize surgical approaches and triceps repair techniques.Level of evidence: Basic Science Study, Anatomic Cadaveric Study.

Surgical treatment of complex distal humeral fractures: Functional outcome after internal fixation using precontoured anatomic plates - Corrected Proof

Kanthan Theivendran, Peter J. Duggan, Subodh C. Deshmukh — 2009-12-28

Hypothesis: Several studies have shown good results with internal fixation of distal humeral fractures; however, few have focused specifically on anatomic parallel plate fixation using the same implant and postoperative regimen. The purpose of this study was to determine the functional outcome after open reduction and internal fixation of these complex fractures using parallel precontoured anatomic plates.Materials and methods: This was a retrospective single-surgeon series involving 16 patients (12 women, 4 men) treated with a double-column parallel plating technique. Clinical assessment included the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand Score (DASH). Mean age was 43 years (range, 20-78 years). Average follow-up was 35 months. Four fractures were AO type A and 12 were AO type C.Results: Union was achieved in all patients. There was no superficial or deep infection or hardware failure. Two patients required removal of plates for pain and prominence but not all screws could be completely removed. The mean flexion was 132° and extension was 29°. The mean DASH score was 46.1. Grip strength was 56% of the uninjured side. Mean flexion and extension force was 72% and 70%, respectively, of the uninjured elbow. The mean MEPS score was 72.3.Discussion: Anatomically precontoured parallel plates are effective in achieving bony union with low implant failure with acceptable functional outcomes. However, screw extraction can be difficult when the implant is removed.Level of evidence: Level 4: Case series; treatment study.

Radiographic and histopathologic analysis of osteolysis after total shoulder arthroplasty - Corrected Proof

2009-12-28

Hypothesis: This study analyzed clinical, radiographic, and histologic data from failed total shoulder arthroplasties (TSAs) to determine factors associated with osteolysis.Materials and methods: From 1985 to 2005, 52 patients (mean age, 61.6 years) underwent revision TSA at a single institution at a mean of 4.3 years after their index surgery. Patients were retrospectively assigned to 2 cohorts based on the presence (n = 10) or absence (n = 42) of osteolysis around their implants on the last prerevision surgery radiographs. Clinical information, associated histopathology from tissues obtained at revision surgery, and polyethylene wear data from the retrieved glenoid components were compared between groups.Results: In the osteolysis group, 20% had screw fixation compared with 2.5% without osteolysis (P = .039). The radiolucency score was significantly higher in the osteolysis group: 12.7 ± 2.0 vs 8.7 ± 3.7 (P = .003). Wear analysis of the osteolysis group demonstrated significant increases in third-body particles compared with those implants without osteolysis (P = .004). Histology available from retrieved implants demonstrated particulate debris in 62% of patients with osteolytic lesions vs 67% without osteolytic lesions (P > .05).Discussion: Significant differences were found in patients with osteolytic lesions compared with patients undergoing TSA revision surgery without such lesions, specifically with regard to glenoids that used adjuvant screw fixation, the presence of increased radiolucent lines, and an abundance of third-body wear. No significant differences were found in particulate wear debris despite the prevailing notion that osteolysis is associated with particulate debris from implant wear.Conclusion: Screw fixation and third-body wear were associated with osteolysis after TSA.Level of evidence: Level 3; Retrospective comparative study.

Intra-articular osteochondroma of the elbow: A case report - Corrected Proof

2009-12-28

Osteochondromas are one of the most common bone tumors of the human skeleton. Also known as osteocartilaginous exostoses, they are benign osseous growths capped with hyaline cartilage. They are also accepted as a hamartoma, which develops from aberrant-growth cartilage. Osteochondromas are classified as either solitary or multiple. Solitary osteochondromas develop in a single bone and are not hereditary. Multiple osteochondromas can occur spontaneously or in an autosomal dominant disorder known as hereditary multiple exostoses.

Regarding “Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws” - Corrected Proof

Ajay Pal Singh, Arun Pal Singh — 2009-12-28

To the Editor: We read with interest the article “Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws” and commend the authors for their work. We would like to raise some questions:

Radiocapitellar joint contacts after bipolar radial head arthroplasty - Corrected Proof

2009-12-28

Purpose: The purpose of this study was to determine radiocapitellar contacts before and after radial head replacement, using the bipolar design of Judet.Methods: Joint contacts were measured by moulding the joint surfaces of 6 fresh-frozen cadaveric specimens, in various positions of elbow flexion and forearm rotation.Results: Expressed as function of the radial cup, contact areas averaged 44% in the normal elbow, decreasing with flexion and increasing with supination (P < .05). After prosthetic implantation, contact areas averaged 33% and remained quite similar, irrespective of elbow position. Subluxation of the prosthetic head over the lateral margin of the trochlea was seen systematically with supination.Conclusions: Because of intraprosthetic mobility, contact areas were not dependant on elbow position. This adaptability, however, also led to abnormal positioning of the prosthetic radial head with supination, subluxing over the trochlea lateral margin.Level of evidence: Basic Science Study, Biomechanical study on cadaveric specimens

Treatment of coracoid process fractures associated with acromioclavicular dislocation using clavicular hook plate and coracoid screws - Corrected Proof

Xiangdong Duan, Huiliang Zhang, Hongbin Zhang, Zhiqiang Wang — 2009-12-14

Coracoid process fractures are relatively uncommon and have been estimated to account for 3% to 13% of all scapular fractures, with scapular fractures in turn accounting for only 1% of all fractures. They were rarely diagnosed before radiography became available, with publications mainly consisting of case reports. Coracoid fracture associated with acromioclavicular (AC) dislocation is the common type, and Ogawa et al reported an occurrence rate of 58%. For a grade III AC dislocation or higher, the operation aims at reduction and internal fixation of the AC joint. This kind of injury may be associated with coracoclavicular (CC) ligament disruption. To date, several surgical techniques involving transarticular screws, Knowles pins, and tension-band wiring have been used to treat coracoid fracture associated with AC dislocation. However, these methods have considerable risks for complications, such as pin migration, loss of reduction, AC joint degeneration, and ankylosis. We carried out an electronic search of the PubMed database and found no articles recommending the use of a clavicular hook plate for coracoid fractures associated with AC dislocation. So, we describe a technique for this kind of injury, using a clavicular hook plate and coracoid screws. This study was approved by the Committee of Medical Section, Affiliated Hospital of North China Coal Medical College, Tangshan Hebei, China (study No. 206).

Arthroscopic capsular release for refractory shoulder stiffness: A critical analysis of effectiveness in specific etiologies - Corrected Proof

2009-12-11

Hypothesis: The purpose of this study is to report and compare the outcome of arthroscopic capsular release in patients with shoulder stiffness with post-traumatic, postsurgical, and idiopathic etiologies. We hypothesize that patients with idiopathic or post-traumatic stiffness have better outcomes after arthroscopic capsular release than those with shoulder stiffness with a postsurgical etiology.Materials and Methods: A retrospective review of 115 patients who underwent arthroscopic capsular release for refractory shoulder stiffness was performed. There were 60 men and 55 women with a mean age of 49 years (range, 27 to 81 years). The patients were divided into 3 groups according to the etiology of stiffness: post-traumatic (26 patients), postsurgical (48 patients), and idiopathic (41 patients). Arthroscopic capsular release was performed in all patients after a mean of 9 months of physical therapy (range, 6 to 13 months).Results: At a mean follow-up of 46 months (range, 25 to 89 months), the overall subjective shoulder value in all groups improved from 29% to 73% and the age- and gender-adjusted Constant score improved from 35% to 86%. The mean pain score decreased from 7.5 to 1, and mean active forward flexion, external rotation, and internal rotation increased from 97°, 14°, and the L5 vertebral level, respectively, to 135°, 38°, and the T11 vertebral level, respectively (P < .0001). There was no significant difference between the outcomes of idiopathic and post-traumatic stiffness (P = .7). However, the Constant score and subjective shoulder value were significantly lower in the postsurgical group compared with the idiopathic and post-traumatic groups (P = .0001 and P = .006, respectively).Conclusions: Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness. Patients with idiopathic and post-traumatic shoulder stiffness have better outcomes than patients with postsurgical stiffness.Level of Evidence: Level IV.

Surgical treatment for lateral epicondylitis: A long-term follow-up of results - Corrected Proof

Brendan Coleman, John F. Quinlan, John A. Matheson — 2009-12-11

Hypothesis: Since its first description, the pathology, natural history, and treatment of lateral epicondylitis have remained controversial. For patients in who conservative management fails, surgery remains an option. The optimal method of surgery remains debatable and is further confounded by a relative lack of long-term follow-up studies.Materials and methods: This study describes a modification of the Nirschl surgical technique and presents its long-term results. Patients undergoing this open technique were reviewed by use of the Hospital for Special Surgery and Mayo elbow performance assessment tools, as well as having grip strength and subjective outcome recorded.Results: From June 1986 to December 2001, 158 consecutive patients (171 elbows) underwent surgery in a single-surgeon series. Of these patients, 137 (86.7%) were available for follow-up at a mean of 9.8 years. The mean age of the group was 42 years. Subjectively, the results were good to excellent in 94.6% of patients and in 92.6% to 94.0% of patients by use of the Hospital for Special Surgery and Mayo scores, respectively. No differences were noted in grip strength. No patient required revision surgery.Conclusions: This repeatable open technique offers excellent results with a low rate of complications at a mean follow-up of 9.8 years. These results compare favorably in terms of numbers followed up, length of follow-up, and outcome and offer strong evidence of its efficacy.Level of evidence: Level IV, Case Series.

The effect of posterior capsular tightening on peak subacromial contact pressure during simulated active abduction in the scapular plane - Corrected Proof

2009-12-11

Hypothesis: Our hypothesis was that tightening of the posterior capsule would lead to increased subacromial pressure and increased superior translation during active abduction in the scapular plane.Background: : Subacromial impingement syndrome is a painful condition that occurs during overhead activities as the rotator cuff is compressed in the subacromial space. Unrecognized secondary causes of subacromial impingement may lead to treatment failure. Posterior capsular tightness, believed to alter glenohumeral joint kinematics, is often cited as a secondary cause of SI; however, scientific evidence is lacking. The primary objective of this study was to evaluate the effect of posterior capsular tightening on peak subacromial pressure during abduction in the scapular plane.Materials and methods: Ten fresh frozen shoulder specimens from deceased donors were mounted on a custom shoulder simulator. With the scapula fixed, the deltoid and rotator cuff muscles were loaded in discrete static steps with a constant ratio to elevate the humerus in the scapular plane. The treatment order (no tightening, 1-cm, and 2-cm tightening of the posterior capsule) was randomly assigned to each specimen. Peak subacromial contact pressure and glenohumeral kinematics at the peak pressure position were compared using a repeated measures analysis of variance.Results: Peak subacromial pressures (mean ± standard deviation) were similar between treatment groups: 345 ± 152, 410 ± 213, and 330 ± 164 kPa for no tightening, 1-cm, and 2-cm tightening of the posterior capsule respectively (P > .05). No significant differences were found for superior or anterior translations at the peak pressure position (P > .05).Discussion: Posterior capsular tightening, as a sole variable, did not contribute to a significant increase in peak subacromial pressure during abduction in the scapular plane. A similar study simulating active forward flexion is necessary to fully characterize the contribution of posterior capsular tightness to subacromial impingement.Conclusion: Tightening of the posterior capsule did not increase subacromial pressure, or increase superior or anterior translation during abduction in the scapular plane.Level of evidence: Basic science study.

Recovery of shoulder strength and proprioception after open surgery for recurrent anterior instability: A comparison of two surgical techniques - Corrected Proof

2009-12-11

Background: Previous studies have documented a decrease in proprioceptive capacity in the unstable shoulder. The degree to which surgical approach affects recovery of strength and proprioception is unknown.Materials and methods: The recovery of strength and proprioception after open surgery for recurrent anterior glenohumeral instability was compared for 2 surgical procedures. A prospective analysis of 55 consecutive patients with posttraumatic unilateral recurrent anterior glenohumeral instability was performed. Thirty patients (group 1) underwent an open inferior capsular shift with detachment of the subscapularis, and 25 (group 2) underwent an anterior capsulolabral reconstruction.Results: Mean preoperative proprioception and strength values were significantly lower for the affected shoulders in both groups. At 6 months after surgery, there were no significant differences for mean strength and proprioception values between the unaffected and operative sides for group 2 patients. In group 1 patients, however, there were still significant deficits in mean position sense and strength values. Complete restoration of proprioception and strength, however, was evident by 12 months in group 1.Conclusion: This study demonstrates that there are significant deficits in both strength and proprioception in patients with posttraumatic, recurrent anterior glenohumeral instability. Although both are completely restored by 1 year after surgery, a subscapularis-splitting approach allows for complete recovery of strength and position sense as early as 6 months postoperatively. Detachment of the subscapularis delays recovery of strength and position sense for up to 12 months after surgery.Level of evidence: Level II.

Pitfalls and complications with locking plate for proximal humerus fracture - Corrected Proof

2009-12-08

Purpose: The aim of this study was to identify specific complications of locking plate fixation of proximal humerus fractures.Patients and Methods: Seventy-threee adult patients with a displaced 3- (24%) or 4-part (76%) fracture of the proximal humerus were treated over a period of 2 years under the supervision of a trauma surgeon. Fourty-four patients came back for a clinical and radiographic examinations at least 18 months after the trauma; the others were evaluated at 6 weeks and 3 and 6 months.Results: Out of the 73 patients (64.4% females, mean age of 65), 11 patients needed a second surgery and 18 were lost for follow-up after 6 months. Mean final constant score was 62.3 points. The incidence of secondary displacement was 8.2%. Nonunion rate was 5.5%, affecting the constant score (P = .018). 16.4% of the patients developed a partial necrosis of the humeral head at the latest follow-up, which influenced on the constant score (P = .029). Quality of the reduction of the greater tuberosity influenced final results (P = .037). Screw cutout rate was 13.7%, with an influence to the constant score (P = .001). A too high plate positioning influenced the constant score (P = .002).Conclusion: Locked screw-plates provide more secure fixation of fractures, especially in weak bone. Complications rate remains high. Two complications are to be distinguished: 1) technical complications in plate positioning, length of the screws or secondary screw cutout strongly influence the final clinical result; and 2) specific complications related to this technology such as pseudarthrosis or plate fracture.Level of evidence: Level 3.

In vitro biomechanical comparison of three different types of single- and double-row arthroscopic rotator cuff repairs: Analysis of continuous bone-tendon contact pressure and surface during different simulated joint positions - Corrected Proof

2009-12-08

Hypothesis: We assessed bone-tendon contact surface and pressure with a continuous and reversible measurement system comparing 3 different double- and single-row techniques of cuff repair with simulation of different joint positions.Materials and methods: We reproduced a medium supraspinatus tear in 24 human cadaveric shoulders. For the 12 right shoulders, single-row suture (SRS) and then double-row bridge suture (DRBS) were used. For the 12 left shoulders, DRBS and then double-row cross suture (DRCS) were used. Measurements were performed before, during, and after knot tying and then with different joint positions.Results: There was a significant increase in contact surface with the DRBS technique compared with the SRS technique and with the DRCS technique compared with the SRS or DRBS technique. There was a significant increase in contact pressure with the DRBS technique and DRCS technique compared with the SRS technique but no difference between the DRBS technique and DRCS technique.Conclusions: The DRCS technique seems to be superior to the DRBS and SRS techniques in terms of bone-tendon contact surface and pressure.Level of evidence: Level 2.

Different scapular kinematics in healthy subjects during arm elevation and lowering: Glenohumeral and scapulothoracic patterns - Corrected Proof

2009-12-08

Hypothesis: The scapulothoracic (ST) joint affects glenohumeral (GH) joint function. We observed 3-dimensional scapular motions during arm elevation and lowering to identify the scapulohumeral rhythm in healthy subjects and to compare it between the dominant and nondominant arms.Materials and methods: Twenty-one healthy subjects participated in this study. Participants randomly elevated and lowered the arms in the scapular plane, and data were recorded by a computerized 3-dimensional motion analyzer at each 10° increment.Results: Of the 42 shoulders, 21 showed a greater ratio of GH motion relative to ST motion whereas the other 21 showed a smaller ratio of GH motion relative to ST motion. The angle of upward rotation of the scapula showed a statistically significant difference between both types. The mean maximum angles of upward rotation, posterior tilting, and internal rotation were 36.2° ± 7.0°, 38.7° ± 5.7°, and 36.8° ± 12.2°, respectively. No significant difference was found in angles of 3 scapular rotations between the dominant and nondominant arms.Discussion: These results indicate that there are 2 distinctly different scapulohumeral rhythms in healthy subjects but without a significant difference between dominant and nondominant arms. These findings should be referred to when one is interpreting kinematics in a variety of shoulder disorders.Level of evidence: Level III.

Complete rotator cuff tendon avulsion and glenohumeral joint incarceration in a young patient: A case report - Corrected Proof

2009-12-07

Rotator cuff tears are a common cause of shoulder pain and dysfunction. Typically, tears in young patients are attributed to repetitive overuse in the overhead throwing athlete. Tears usually occur in the supraspinatus tendon and extend posteriorly into the infraspinatus tendon. Although less common, traumatic shoulder injuries can result in significant rotator cuff contusion and tears in young patients. Anterosuperior rotator cuff tears involving the subscapularis as well as the supraspinatus tendons have been described. We report an unusual case of a complete rotator cuff tendon avulsion with glenohumeral joint incarceration after significant trauma to the shoulder.

Interobserver and intraobserver reliability of the Walch classification in primary glenohumeral arthritis - Corrected Proof

2009-12-07

Introduction: In 1999, Walch et al introduced a novel classification scheme for glenoid morphology in patients with primary glenohumeral arthritis and reported substantial intraobserver and interobserver reliability. This classification system has been widely used by shoulder surgeons but a recent independent evaluation revealed considerable lower agreement. The goal of this study was to evaluate the reproducibility of the Walch classification.Material and methods: Twenty-three consecutive patients (26 shoulders) undergoing total shoulder arthroplasty (TSA) or evaluated for TSA between March 2007 and November 2007 had shoulder CT scans performed and were included in this study. Three attending shoulder surgeons and 5 shoulder/sports medicine trained fellows independently and blindly evaluated CT scans of 26 consecutive patients with primary glenohumeral arthritis, and classified each patient according to the Walch classification to determine the interobserver reliability. The intraobserver reliability was assessed by comparison of the classification of each patient by the observers on 2 occasions separated by at least 6 weeks.Results: The overall interobserver agreement for all 8 observers was moderate (k=.508) for all Walch classes. The overall intraobserver reproducibility was substantial (k=.611).Discussion: We have shown that the interobserver reliability of the Walch classification is moderate while the intraobserver reliability is substantial. This is similar to or superior to the reliability of many commonly used orthopaedic classification systems. While the Walch classification system is not as reliable as initially suggested and improvement of this classification system would be of utility for future clinical studies, we have shown that this is an acceptable classification system and has good clinical and research applications.Level of Evidence: I, Testing of Previously Developed Criteria in Consecutive Series, Diagnostic Study.

Effect of sodium hyaluronate treatment on rotator cuff lesions without complete tears: A randomized, double-blind, placebo-controlled study - Corrected Proof

2009-12-07

Hypothesis: A randomized, double-blind, placebo-controlled study of sodium hyaluronate (ARTZ Dispo) treatment was performed in 51 patients with rotator cuff lesions without complete tears. We hypothesized that ARTZ Dispo would render better results than the placebo.Materials and methods: Twenty-five patients (ARTZ Dispo group) had injections of 25 mg/wk of sodium hyaluronate into the subacromial bursa for 5 consecutive weeks. Twenty-six patients (placebo group) were given 2.5 mL of normal saline solution with the same injection protocol as the ARTZ Dispo group. No significant difference in age, height, weight, gender, vocation, involved shoulder, duration of symptoms, baseline Constant score, or visual analog scale (VAS) score existed between the 2 groups.Results: The 2 groups did not significantly differ with regard to Constant scores, VAS scores, or global improvement assessments 1 week after injections. The ARTZ Dispo group had a better Constant score (P = .0095) and VAS score (P = .0018) than the placebo group 6 weeks after treatment. Patients in the placebo group were given 5 sodium hyaluronate injections, rather than placebo, after disclosure of the blind list, if they wished. Forty-one patients who underwent hyaluronate injection exhibited a significantly improved Constant score, from 64.0 ± 11.7 at baseline to 88.9 ± 10.4 (P < .0001), and a significantly improved VAS score, from 6.4 ± 1.3 to 1.5 ± 1.6 (P < .0001), at a mean follow-up of 33.1 months. No significant adverse effect was noted.Conclusions: Subacromial injections of sodium hyaluronate are effective in treating rotator cuff lesions without complete tears.Level of evidence: Level 1; randomized clinical trial and treatment study.

The results of ORIF of displaced unstable proximal humeral fractures using a locking plate - Corrected Proof

Xavier A. Duralde, Lee R. Leddy — 2009-12-07

Background/hypothesis: Surgical management of displaced unstable proximal humerus fracture remains a challenge due to poor proximal bone quality and significant deforming forces. We hypothesized that the technique of application and mechanical properties of the proximal humeral locking plate would allow successful treatment of unstable and displaced proximal humeral fractures even in the face of osteoporotic bone.Method: We evaluated prospectively the results of open reduction internal fixation of 22 displaced unstable proximal humerus fractures in 22 patients utilizing a proximal humeral locking plate.Results: Results according to the ASES scoring system at a minimum of 2 years were excellent in 13, good in 4, fair in 1, and poor in 3. One patient was lost to follow-up. All fractures healed. Anatomic alignment was obtained in 72%. Two patients developed avascular necrosis of the humeral head. There were no cases of hardware failure, infection, or loss of reduction. Three separate reduction maneuvers were employed in this series depending on fracture type.Conclusion: The locking plate is an excellent device in the management of displaced unstable proximal humeral fractures and is expanding the indications for ORIF in these fractures.Level of Evidence: Therapeutic Study Level II.

Subscapularis muscle metastases of duodenal adenocarcinoma: A case report - Corrected Proof

Young-Lae Moon, Ki Yong Ahn, Sung Pyo Moon, Sung-Chul Lim, Gorthi Venkat — 2009-12-07

In view of the rarity of metastases to the muscles from a gastrointestinal malignant tumor and the lack of any reports of metastases to the subscapularis muscle from the gastrointestinal tract in the literature, we report a very rare case of subscapularis muscle metastases of duodenal adenocarcinoma in an elderly female patient with nonspecific anterior shoulder pain.

Identification and management of “floating” posterior inferior glenohumeral ligament lesions - Corrected Proof

Chris Pokabla, E. Rhett Hobgood, Larry D. Field — 2009-12-03

Recurrent posterior glenohumeral instability, although a less common clinical entity than anterior instability, must be recognized and appropriately treated for a successful outcome. Pathologic findings that may need to be addressed include posterior Bankart lesions, humeral avulsion of the posterior inferior glenohumeral ligament (PIGHL), intrasubstance ligament attenuation, and combined lesions. In this review, we present 2 patients with the same pathoanatomic findings of recurrent posterior shoulder instability secondary to posterior humeral avulsion of the glenohumeral ligament with an associated posterior Bankart lesion. This combination of pathology is referred to as a “floating PIGHL” lesion. We review both patient's preoperative clinical findings and imaging studies and detail the necessary steps for a successful repair.

Three-dimensional osseous micro-architecture of the distal humerus: Implications for internal fixation of osteoporotic fracture - Corrected Proof

2009-12-03

Background: The purpose of this study is to analyze 3-dimensional structural parameters of cortical and trabecular bone in the distal humerus using quantitative CT and to find regional variations and differences according to age.Methods: We collected 14 cadaveric distal humeri with an average age of 58.4 years. The specimens were examined at 3 different levels: 1) distal trans-epicondylar section, 2) mid trans-olecranon fossa section, and 3) proximal supra-olecranon fossa section.Results: In the distal section, bone volume was the greatest in the anterior part of the lateral condyle and the least in the posterior part of the lateral condyle. Cortical thickness in the distal section was the thickest in the posterior medial and the thinnest in the anterior aspect followed by lateral aspect. The changes in cortical thickness with aging were obvious in the posterior side and trabecular bone on the medial condyle.Conclusion: This study evaluated the differences in cortical and trabecular bone parameters in each different region of the distal humerus. We found a potential weakness of plate fixation in the posterolateral aspect of the distal condyle because of relative insufficient osseous micro-architecture, which may affect the treatment of osteoporotic distal humerus fractures especially in elderly patients.Level of evidence: Basic science study, anatomic cadaver study.

Restoring range of motion via stress relaxation and static progressive stretch in posttraumatic elbow contractures - Corrected Proof

2009-12-03

Hypothesis: Loss of range of motion after injury or surgery of the elbow is a common complication. We hypothesized that an orthosis that used progressive stretch and stress relaxation principles would improve elbow range of motion.Methods: This study evaluated the result of a patient-directed, bidirectional orthosis that uses static progressive stretch and stress relaxation principles to improve elbow range of motion in patients who had posttraumatic elbow contractures. Treatment in 37 elbows consisted of a 30-minute stretching protocol performed in 1 to 3 sessions daily for a mean of 10 weeks (range, 2-22 weeks).Results: The mean gain in range of motion was 26° (range, 2°-60°). Gains of motion were noted in 35 of 37 elbows. Patients lowered their analgesic use and were highly satisfied with the device (mean satisfaction score of 8.5 of 10 points possible).Discussion: This device compared favorably with reports of other devices. Consistent improvements in restoring range of motion can be achieved with short treatment times by using a device based on the principles of static progressive stretch and stress relaxation in patients with posttraumatic elbow contractures.Level of evidence: Level 4; Case series.

The outcome of ultrasound-guided needle decompression and steroid injection in calcific tendinitis - Corrected Proof

2009-12-03

Hypothesis: Needle lavage is frequently performed before consideration of surgical removal in shoulders with calcific tendinitis because this may avoid surgery. However, its role in nonoperative treatment has not been fully investigated in terms of clinical and radiographic response. We hypothesized that needle decompression and subacromial steroid injection would show good clinical results in chronic calcific tendinitis patients.Materials and methods: Thirty-five shoulders in 30 consecutive patients with painful calcific tendinitis were treated by ultrasound-guided needle decompression and subacromial corticosteroid injection. Patients were prospectively evaluated using American Shoulder and Elbow Surgeons (ASES) and Constant scores at 1, 3, and 6 months after the intervention. Size and morphology of the calcific deposits were compared with those in baseline radiographs at each visit.Results: At 6 months after the index procedure, 25 shoulders (71.4%) showed ASES and Constant score improvements from 48.0 and 53.7 to 84.6 and 87.9, respectively (P < .01). Ten shoulders (28.6%) showed no symptom relief at the last follow-up. In shoulders with pain improvement, the mean size of calcific deposits reduced from 13.6 to 5.6 mm (P < .01), and in shoulders with no pain improvement or that underwent operation, mean size was 13.1 mm at initial visits and 12.7 mm at final visits (P = .75).Discussion: Shoulders showing little evidence of deposit size reduction at 6 months after needle decompression are less likely to achieve symptomatic improvement and may be considered as candidates for surgical removal.Conclusion: Needle decompression with subacromial steroid injection is effective in 71.4% of calcific tendinitis within 6 months. The size of calcific deposits in patients that achieved symptom relief was reduced.Level of evidence: Level 4; Case series, treatment study.

Accuracy of CT-based measurements of glenoid version for total shoulder arthroplasty - Corrected Proof

Heinz R. Hoenecke, Juan C. Hermida, Cesar Flores-Hernandez, Darryl D. D'Lima — 2009-12-03

Background/Hypothesis: The arthritic glenoid is typically in retroversion and restoration to neutral version is recommended. While a method for measurement of glenoid version using axial computed tomography (CT) has been reported and has been widely accepted, its accuracy and reproducibility has not been established.Methods: In 33 patients scheduled for shoulder arthroplasty, glenoid version and maximum wear of the glenoid articular surface were measured with respect to the scapular body axis on 2-dimensional- (2D) CT slices as well as on 3-dimensional- (3D) reconstructed models of the same CT slices.Results: Clinical CT scans were axially aligned with the patient's torso but were almost never perpendicular to the scapular body. The average absolute error in version measured on the 2D-CT slice passing through the tip of the coracoid was 5.1° (range, 0 - 16°, P < .001). On high-resolution 3D-CT reconstructions, the location of maximum wear was most commonly posterior and was missed on the clinical 2D-CT slices in 52% of cases.Conclusion: Error in measuring version and depth of maximum wear can substantially affect the determination of the degree of correction necessary in arthritic glenoids. Accurately measuring glenoid version and locating the direction of maximum wear requires a full 3D-CT reconstruction and analysis.Level of Evidence: Level 1; Diagnostic Study.

Italian cross-cultural adaptation and validation of the Oxford shoulder score - Corrected Proof

Luigi Murena, Ettore Vulcano, Fabio D'Angelo, Maria Monti, Paolo Cherubino — 2009-11-06

Background: The Oxford Shoulder Score (OSS) is an English-language questionnaire specifically designed to evaluate patients affected by shoulder pain. Although this scoring system has been translated into other languages, an Italian version of it is still not available. The aim of the present study was to translate, culturally adapt, and validate the Italian version of the OSS.Materials and methods: We recruited 140 patients with shoulder pain caused by degenerative or inflammatory state or disorder of the shoulder. Patients completed the following questionnaires: Italian OSS, University of California, Los Angeles (UCLA) Shoulder Rating Scale, Constant-Murley shoulder assessment, and the Medical Outcome Study Short-Form 36 Health Survey (MOS SF-36). Internal consistency was tested using Cronbach coefficient α. Reproducibility was assessed by asking 110 patients to complete another OSS 48 hours after the first. Correlation between the total results of both tests was determined by the Pearson correlation coefficient. Validity was assessed by calculating the Pearson correlation coefficient between the OSS and the UCLA, Constant-Murley, and SF-36 assessments.Results: Cronbach α was 0.95. The Pearson correlation coefficient was r=0.97. With respect to validity, there was a significant correlation between the Italian OSS and the individual scores of UCLA, Constant-Murley, and SF-36.Discussion: Psychometric properties of the Italian OSS compared well with those reported for the English OSS. As demonstrated by the high values of Cronbach α and Pearson correlation coefficients, in accordance with the English version of the OSS, the Italian version proved to be a reliable, valid, and reproducible measure of shoulder pain perception in Italian-speaking patients.Level of evidence: Level 1; Test of previously developed criteria, diagnostic test study.

Propionibacterium acnes infection after shoulder arthroplasty: A diagnostic challenge - Corrected Proof

2009-11-02

Hypothesis: This study reviewed a series of patients diagnosed with Propionibacterium acnes infection after shoulder arthroplasty in order to describe its clinical presentation, the means of diagnosis, and provide options for treatment.Materials and methods: From 2002 to 2006, 11 patients diagnosed with P acnes infection after shoulder arthroplasty were retrospectively reviewed and analyzed for (1) clinical diagnosis; (2) laboratory data, including white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); (3) fever; (4) number of days for laboratory growth of P acnes; (5) organism sensitivities; (6) antibiotic regimen and length of treatment; and (7) surgical management. Infection was diagnosed by 2 positive cultures.Results: Five patients had an initial diagnosis of infection and underwent implant removal, placement of an antibiotic spacer, and staged reimplantation after a course of intravenous antibiotics. In the remaining 6 patients, surgical treatment varied according to the clinical diagnosis. When infection was recognized by intraoperative cultures, antibiotics were initiated. The average initial ESR and CRP values were 33 mm/h and 2 mg/dL, respectively. The average number of days from collection to a positive culture was 9. All cultures were sensitive to penicillin and clindamycin and universally resistant to metronidazole.Discussion: Prosthetic joint infection secondary to P acnes is relatively rare; yet, when present, is an important cause of clinical implant failure. Successful treatment is hampered because clinical findings may be subtle, many of the traditional signs of infection are not present, and cultures may not be positive for as long as 2 weeks.Level of evidence: Level IV; Case series, Treatment study.

Implications of revision total elbow arthroplasty on blood transfusion - Corrected Proof

Matthew P. Abdel, Bernard F. Morrey — 2009-11-02

Hypothesis: We hypothesize that there is a greater rate of blood transfusions following revision total elbow arthroplasty (TEA) as compared with primary TEA, with lower preoperative hemoglobins and longer operative times being significant risk factors.Materials and methods: The results of 193 operations (172 patients) between January 2000 and December 2004 were retrospectively reviewed. Excluded were patients with primary impairment of platelet or coagulation function or with chronic liver impairment. Univariate and χ2 analyses were used to determine which risk factors were predictive of transfusion.Results: The transfusion rate was 7.8% for revision arthroplasties and 1.0% after primary procedures (P < .02). Revision surgery (P < .02), longer operative times (P < .01), longer anesthesia times (P < .01), lower preoperative hemoglobin level (10.6±0.5 g/dL; P < .01), and lower body mass index (P=.04) significantly increased the risk of blood transfusion.Discussion: The need for blood transfusion after revision elbow arthroplasty is statistically greater than that after primary procedures. Furthermore, revision surgery, increased operative and anesthesia times, lower preoperative hemoglobin level, and decreased body mass index increase the risk of requiring a transfusion. Patients undergoing revision surgeries with preoperative hemoglobin levels of less than 10 g/dL are especially at risk of transfusion, and the proper precautions should be enacted during the perioperative period.Level of evidence: Level 4; Case series, treatment study.

The outcome of examination (manipulation) under anesthesia on the stiff elbow after surgical contracture release - Corrected Proof

Arash Araghi, Andrea Celli, Robert Adams, Bernard Morrey — 2009-10-19

Hypothesis: We have used a technique of elbow examination under anesthesia in select patients after surgical release to assess the smoothness of the articulation, evaluate stability, and to stretch the flexion and rotation arcs.Materials and methods: The study comprised 51 consecutive patients who underwent an examination under anesthesia between January of 1996 and December of 2001.Results: The examination occurred a mean of 40 days after surgery. Forty-four patients with a minimum of 12 months follow-up revealed a mean pre-examination arc of 33°, which improved to 73° at the final assessment. Three patients had no appreciable change (<10°) in the total arc, and 1 patient lost motion. Four patients underwent a second examination under anesthesia at a mean of 119 days after the first examination. The average pre-examination arc of 40° increased to 78° at the final assessment (mean improvement, 38°). The only complication was worsening of ulnar paresthesias in 3; with 2 resolving spontaneously, and 1 patient requiring anterior ulnar nerve transposition.Conclusions: Examination (manipulation) under anesthesia can be a valuable adjunctive procedure to help regain the motion obtained at the time of surgical release. Because this was not a controlled series, additional studies might be conducted to refine those not benefiting from this procedure. In our series no permanent complications were noted.Level of evidence: Level IV, Case Series, Treatment Study.

Results of treatment of luxatio erecta (inferior shoulder dislocation) - Corrected Proof

Gordon I. Groh, Michael A. Wirth, Charles A. Rockwood — 2009-10-19

Hypothesis: Traumatic inferior shoulder dislocation (luxatio erecta) injuries are rare, comprising less than 0.5% of all shoulder dislocations. Few cases have been reported, and the outcome of treatment has been ill defined.Materials and methods: Between 1968 and 2000, 18 patients (20 shoulders) with luxatio erecta were evaluated at our institution. Two patients (2 shoulders) were lost to follow-up, leaving 16 patients (18 shoulders) for long-term follow-up (average, 9 years). Associated injuries included peripheral nerve injury, humeral fracture, acromial fracture, and rotator cuff tear. All patients were initially managed with closed reduction, which was successful in 9 shoulders. The remaining 9 shoulders required operative treatment.Results: Patients were evaluated with respected to pain, function, range of motion, strength, and patient satisfaction, according to the University of California at Los Angeles Rating Scale. Overall, 13 of the 16 patients were graded as good or excellent. Patients treated with closed reduction or operative treatment compared favorably in terms of improvements in ratings for pain, strength, motion, and the ability to perform work and sports.Discussion: Our experience suggests that treatment of luxatio erecta is largely successful, with good or excellent results obtained in 83% of the shoulders. Half of the patients evaluated, required only closed reduction as their definitive treatment. Operative treatment is typically indicated for associated displaced humeral head fractures or patients with recurrent instability. Recurrent instability appears to be more likely in patients with a previous history of dislocation. Associated neurologic or vascular injury did not affect the final outcome.Level of evidence: Level IV, Case Series, Therapeutic Study.

Radiocapitellar prosthetic arthroplasty for capitellar nonunion - Corrected Proof

Christopher K. Kepler, Jennifer L. Kummer, Dean G. Lorich, Andrew J. Weiland — 2009-10-19

Elbow arthroplasty is complicated by the presence of 3 distinct articulations within the native elbow joint. Orthopedic surgeons have traditionally relied on a simple hinged prosthesis for elbow arthroplasty, despite obvious limitations compared with the complexity of movement in the native joint. This concept provides acceptable pain relief and function in the elderly and other lower-demand patient groups, such as those with rheumatoid arthritis; however, total elbow arthroplasty (TEA) is less appealing in younger patients because of activity limitations and concern about long-term implant survival.

In chronic lateral epicondylitis, apoptosis and autophagic cell death occur in the extensor carpi radialis brevis tendon - Corrected Proof

Jimin Chen, Allan Wang, Jiake Xu, Minghao Zheng — 2009-10-19

Hypothesis: Despite its common occurrence, lateral epicondylitis is poorly understood from a cellular and molecular perspective. We hypothesize that apoptosis and autophagic cell death are involved in the development of chronic lateral epicondylitis.Materials and methods: In 10 patients undergoing surgery for chronic recalcitrant lateral epicondylitis, tendon samples were taken from the extensor carpi radialis brevis (ECRB) tendon and were processed for hematoxylin and eosin, terminal deoxynucleotidyl transferase-mediated deoxy uridine triphosphate nick-end labeling (TUNEL) assay, and immunostaining. Extracellular matrix structure was graded I to III according to collagen fiber structure and arrangement. Apoptotic rate, autophagic cell death rate, cell density, and type I collagen content were measured and compared between areas with different collagen grade.Results: Apoptotic and autophagic cell death occur in the ECRB tendon and varied with the grade of collagen structure. In grade I matrix with relatively less disrupted collagen structure, the apoptosis rate was 23.2% ± 4.8% and the autophagy cell death rate was 7.6% ± 2.2%. In grade II matrix with more advanced breakdown of collagen structure, the apoptosis rate increased to 34.4% ± 4% (P < .05) and the autophagic cell death rate to 13.7% ± 3% (P < .05).Discussion: This study demonstrated that apoptosis and autophagic cell death occur in the ECRB tendon in chronic lateral epicondylitis. The markedly elevated apoptotic rate and autophagic cell death rate in the grade II matrix may be responsible for the decrease in cellularity and further deterioration of collagen quality seen in end-stage grade III matrix, and this eventually compromised the tendon's ability to maintain its integrity and resulted in tendon tear.Conclusion: Both apoptosis and autophagic cell death play an important role in the development of tendon degeneration in chronic lateral epicondylitis.Level of evidence: Basic science study.

Conservative management of proximal humeral fractures: Can poor functional outcome be related to standard transscapular radiographic evaluation? - Corrected Proof

Martijn Poeze, Anton F. Lenssen, Joey M. Van Empel, Jan P. Verbruggen — 2009-10-19

Hypothesis: Functional outcome after conservative management is predicted by changes in angulation of the fractured humeral head and can be used for individual patients to predict functional outcome.Materials and methods: Standard anteroposterior (AP) and transscapular (Y) radiographs were used to evaluate 55 patients with minimally displaced proximal humeral fractures during the first week of conservative treatment. Functional outcome was determined by the Constant-Murley and Disabilities of Arm, Shoulder and Hand (DASH) scores. The relationship between the variables and the radiographic evaluation was assessed by the Pearson correlation coefficient. Receiver operator curve (ROC) analysis and logistic regression analysis defined the optimal value for abnormalities on radiographic evaluation as an outcome predictor.Results: Mean (SD) angulations at time of the fracture were 53° (19°) on AP view and 59° (21°) on Y-view. After 1 week, these angulations were 47° (20°) and 62° (21°), respectively. Significant correlations between Constant-Murley (R2=0.43, P=.007) and DASH (R2=0.43, P=.04) outcome scores and the angulation of the humeral head fragment on the Y view, and not with AP angulation were found. The optimum predictive angulation at the Y view at time of fracture was 55° or less for predicting adverse functional outcome with an area under the ROC curve of 0.78 (95% confidence interval [CI], 0.64-0.93; P=.006). Regression analysis showed that angulations on the initial Y view and after 1 week were the most important predictors of the functional outcome at a median of 2.2 years of follow-up.Conclusion: This study indicated that radiographic evaluation in patients with minimally displaced proximal humeral fractures is helpful in prediction functional outcome during conservative treatment.Level of evidence: Level 2; Retrospective study, prognostic study.

Management of proximal humeral fractures: Surgeons don't agree - Corrected Proof

2009-10-05

Hypothesis: The management options for proximal humeral fractures have expanded in recent years. Patients with displaced, unstable proximal humeral fractures may have improved outcomes if managed operatively. We investigated the decision making of fellowship-trained orthopedic surgeons when presented with the same group of cases. We hypothesized that interobserver and intraobserver agreement for surgical management would be poor and independent of fellowship training.Method: Eight fellowship-trained orthopedic surgeons (3 shoulder, 5 trauma) viewed the preoperative plain radiographs of patients with proximal humeral fractures. All surgeons viewed the same 38 radiographs in a blinded fashion. Surgeons chose from 1 of 6 management options. Interobserver variability was calculated by using the weighted κ coefficient. Intraobserver variability was calculated by comparing each surgeon's survey results with the operation they originally performed.Results: Overall interobserver agreement on management was moderate (weighted κ=0.41) and did not differ significantly between trauma surgeons and shoulder surgeons. Reducing the number of management choices increased agreement between all surgeons. Testing for intraobserver agreement showed that surgeons picked the same operation in the survey as in the actual clinical setting only 56% of the time.Conclusion: Interobserver agreement was moderate overall and improved when the number of management choices was reduced. Intraobserver agreement was less frequent, however, raising the question about consistent decision making by a given surgeon. Although surgeons agree in the method of treatment only to a modest degree, it remains for further outcomes research to establish if the choice of treatment actually influences the clinical outcome.Level of evidence: Level 4, case series.

Radiologic course of the calcific deposits in calcific tendinitis of the shoulder: Does the initial radiologic aspect affect the final results? - Corrected Proof

Nam Su Cho, Bong Gun Lee, Yong Girl Rhee — 2009-10-05

Hypothesis: Although conservative treatment is the first option for the treatment of calcific tendinitis, only a few reports have described its results, without documenting the radiologic changes over time of calcific deposits. We hypothesized that conservative treatment for calcific tendinitis of the shoulder would produce good clinical results in most patients and that the initial radiologic appearance of calcific deposits would not affect the final results.Materials and methods: The study enrolled 87 consecutive patients (92 shoulders) who were diagnosed with calcific tendinitis and underwent conservative treatment. The mean age at the time of first visit was 53.2 years. The mean follow-up period was 16.1 months.Results: At the final follow-up, the Constant score increased to 83.64 points from a mean of 76.17 points at initial visit (P < .001). The score on the University of California, Los Angeles (UCLA) Shoulder Rating Scale improved from 23.42 to 29.69 points (P < .001), and there were 7 excellent (8%), 59 good (64%), and 26 poor (28%) results. Eleven shoulders (12%) revealed complete resolution of calcific deposits; 46 (50%) decreased in size; 18 (20%) had no change in size; and 17 (18%) increased in size.Discussion: Most patients in calcific tendinitis require treatment due to very severe shoulder pain, and conservative treatment may take precedence over operative treatment. Radiologic changes of calcific deposits report varying results depending on treatment methods. This study suggested that good radiologic results may be expected without performing special therapies.Conclusion: Conservative treatment for calcific tendinitis of the shoulder showed clinically significant improvement, with 72% of excellent or good results regardless of the location, radiologic type and size, and initial symptoms of calcific deposits. By radiologic type, 46% of the calcific deposits had a tendency to become more cloudy and inhomogeneous than initial findings, and 62% presented complete resolution or decrease in the size.Level of evidence: IV, Case Series, Treatment Study.

The effect of matrix metalloproteinase inhibition on tendon-to-bone healing in a rotator cuff repair model - Corrected Proof

2009-10-05

Hypothesis: Recent studies have demonstrated a potentially critical role of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in the pathophysiology of rotator cuff tears. We hypothesize that local delivery of a MMP inhibitor after surgical repair of the rotator cuff will improve healing at the tendon-to-bone surface interface.Materials and methods: Sixty-two male Sprague-Dawley rats underwent acute supraspinatus detachment and repair. In the control group (n=31), the supraspinatus was repaired to its anatomic footprint. In the experimental group (n=31), recombinant α-2-macroglobulin (A2M) protein, a universal MMP inhibitor, was applied at the tendon-bone interface with an identical surgical repair. Animals were sacrificed at 2 and 4 weeks for histomorphometry, immunohistochemistry, and biomechanical testing. Statistical comparisons were performed using unpaired t tests. Significance was set at P < .05.Results: Significantly greater fibrocartilage was seen at the healing enthesis in the A2M-treated specimens compared with controls at 2 weeks (P < .05). Significantly greater collagen organization was observed in the A2M-treated animals compared with controls at 4 weeks (P < .01). A significant reduction in collagen degradation was observed at both 2 and 4 weeks in the experimental group (P < .05). Biomechanical testing revealed no significant differences in stiffness or ultimate load-to-failure.Conclusion: Local delivery of an MMP inhibitor is associated with distinct histologic differences at the tendon-to-bone interface after rotator cuff repair. Modulation of MMP activity after rotator cuff repair may offer a novel biologic pathway to augment tendon-to-bone healing after rotator cuff repair.Level of evidence: Basic science study

Results after delayed axillary nerve reconstruction with interposition of sural nerve grafts - Corrected Proof

Beat K. Moor, Mathias Haefeli, Samy Bouaicha, Ladislav Nagy — 2009-10-05

Hypothesis: Satisfactory results after repair of isolated axillary nerve lesions using sural nerve autografts have been reported, but a delay between injury and surgical repair exceeding 6 months was one of the most important negative predictors of functional outcome. From our experience, we hypothesize that good results can be obtained even after a delay exceeding 6 months and we opted in this study to assess the value of delayed axillary nerve reconstruction.Materials and methods: We evaluated clinical outcome and donor-site morbidity in 12 patients (mean age, 37; range, 19-66 years) who underwent axillary nerve repair with sural nerve graft with an average 11.25-month a delay between trauma and surgery (range, 8-20 months). Follow-up examination at least 24 months after treatment included assessment of shoulder range of motion, deltoid muscle strength in near full extension, deltoid extension lag, and sensibility. Constant Score, subjective shoulder value, and the Disabilities of Arm, Shoulder and Hand score were also assessed.Results: All patients showed an improved deltoid function of at least M3. Postoperative extension lag, as the most specific sign of isolated deltoid function, improved from 57.5° to 14.2°. All stated that they would have identical elective surgery again. Relevant donor-site morbidity was not observed.Conclusion: Our data indicate that even delayed axillary nerve grafting may lead to satisfactory functional results with a low morbidity and should therefore be done in selected patients.Level of evidence: Level IV, Case Series, Treatment Study.

Is a formal physical therapy program necessary after total shoulder arthroplasty for osteoarthritis? - Corrected Proof

2009-10-05

Hypothesis: A retrospective analysis was conducted of 2 consecutive groups of patients undergoing total shoulder arthroplasty (TSA) for primary osteoarthritis. One group was treated with formal physical therapy (PT), and one group was treated with home-based, physician-guided PT. We hypothesized that patients with a formal postoperative PT protocol would have significantly better postoperative clinical outcomes than patients with no formal PT.Methods: Group A (43 patients) had a standard PT program. Group B (38 patients) had a home-based, physician-guided PT program. Clinical outcomes (preoperatively, 3, 6, and 12 months and most recent follow-up) were analyzed. A minimum sample size of 31 patients gives power to detect a 10-point American Shoulder and Elbow Surgeons (ASES) score (α=0.05, β=0.80).Results: ASES and Simple Shoulder Test (SST) scores significantly improved in both groups at all follow-up periods. Forward flexion and abduction were significantly improved in group B at all time points, whereas an initial improvement in forward flexion and abduction in group A was lost at final follow-up. There were no significant differences in final ASES or SST scores between groups at final follow-up. However, forward flexion, abduction, and the Short Form-36 physical component summary in group B were significantly better than group A at final follow-up. No significant improvements in internal rotation or SF-36 mental component summary were seen within or between the groups at final follow-up. Overall, there was no difference in patient satisfaction, with 88% satisfaction in group A and 95% satisfaction in group B (χ2=0.471, P=.4924).Conclusions: A home-based, physician-guided therapy program may provide adequate rehabilitation after TSA, allowing for a reduction in cost for the overall procedure.Level of evidence: Level III, Case-Control Study, Therapeutic Study.

Nonoperative management of adhesive capsulitis of the shoulder: Oral cortisone application versus intra-articular cortisone injections - Corrected Proof

2009-10-05

Hypothesis: Oral and intra-articular injections of cortisone will lead to significant improvement and comparable results in the treatment of adhesive capsulitis of the shoulder.Materials and methods: In a prospective randomized evaluation, 40 patients with idiopathic adhesive capsulitis of the shoulder were treated with an oral corticoid treatment regimen or 3 intra-articular injections of corticosteroids. Follow-up was after 4, 8, and 12 weeks, and 6 and 12 months. For the clinical evaluation, the Constant-Murley (CM) score, the Simple Shoulder Test (SST) and visual analog scales (VAS) for pain, function, and satisfaction were used.Results: In the patients treated with oral glucocorticoids, significant improvements were found for the CM score (P < .0001), SST (P=.035), VAS (P < .0001), and range of motion (P < .05) at the 4-week follow-up. The patients treated with an intra-articular glucocorticoid injection series also significantly improved in the CM score (P < .0001), SST (P < .0001), the VAS (P < .0001), and range of motion (P < .05) after 4 weeks. These results were confirmed at all other follow-up visits. Superior results were found for intra-articular injections in range of motion, CM score, SST, and patient satisfaction (P < .05). Differences in the VAS for pain and function were not significant (P > .05).Discussion: The use of cortisone in the treatment of idiopathic shoulder adhesive capsulitis leads to fast pain relief and improves range of motion. Intra-articular injections of glucocorticoids showed superior results in objective shoulder scores, range of motion, and patient satisfaction compared with a short course of oral corticosteroids.Level of evidence: Level 1, Randomized Clinical Trial, Treatment Study.