Journal of Shoulder and Elbow Surgery

Isometric strength, range of motion, and impairment before and after total and reverse shoulder arthroplasty

2013-01-14

Background: Medicare Part A provides similar resources for coverage of inpatient hospitalization costs for patients treated with total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA). This is based on an assumption that TSA and RSA are used to treat similar patient populations with comparable disease severity. However, no objective clinical information is available to support this resource allocation. The purpose of this study is to quantify the disease severity and subsequent improvement from primary TSA, primary RSA, and revision arthroplasty (TSA and RSA).Methods: From March 2004 through May 2006, 174 shoulders (87 primary TSA, 55 primary RSA, and 32 revision cases) were prospectively studied using Biodex (Biodex Medical Systems, Shirley, NY, USA) isometric strength and standardized video range of motion measurements performed by an independent third-party observer at 1 week before surgery and at an average of 49 months (range, 32-69 months) postoperatively. Patient impairment ratings were calculated using the Florida Impairment Guidelines.Results: Primary TSA had the lowest average preoperative impairment (21%), and revision arthroplasty had the highest (28%). All patients demonstrated improvement in the parameters tested. At an average 49 months, all 3 groups demonstrated a similar reduction in impairment ratings (TSA: 21% to 10%; RSA: 25% to 15%; revision arthroplasties: 28% to 20%).Conclusion: There are distinct differences in preoperative disease severity among patients undergoing primary TSA, primary RSA, and revision arthroplasty. Greater impairment is evident in patients undergoing a revision arthroplasty. However, all groups may be expected to achieve improvements and maintain these improvements 4 years postoperatively.

Hemiarthroplasty vs total shoulder replacement for rotator cuff intact osteoarthritis: how do they fare after a decade?

Michael J. Sandow, Huw David, Steven J. Bentall — 2013-01-18

Background: We compared hemiarthroplasty (HA) and total shoulder replacement (TSR) for the treatment of osteoarthritis at minimum of 10 years from primary arthroplasty.Methods: Thirty-three patients (13 HA and 20 TSR) were intraoperatively randomized to HA or TSR after glenoid exposure and were assessed to a minimum of 10 years postoperatively. Apart from those who died, no patients were lost to follow-up.Results: At 6 months and 1 year, the TSR patients had less pain than the HA patients (P < .05), and this became more apparent at 2 years postoperatively (P < .02). There were no statistically significant differences between the groups at 10 years with respect to pain, function, and daily activities. No patients in the HA group rated their shoulders as pain-free at 10 years; however, 42% of the surviving TSR patients rated their shoulders as pain-free at 10 years. Four HA patients were revised to TSR due to severe pain secondary to glenoid erosion. Two shoulders in the TSR group have been revised. Nine of the 13 HA patients (69%) and 18 of the 20 TSR patients (90%) remained in situ at death or at the 10-year review.Conclusion: TSR has advantages over HA with respect to pain and function at 2 years, and there has not been a reversal of the outcomes on longer follow-up. This longer-term review does not support the contention that HA will avoid later TSR complications, and in particular, an unacceptable rate of glenoid component failure.

The role of eccentric and offset humeral head variations in total shoulder arthroplasty

2013-01-14

Background: Humeral head variations were developed based on anatomic and biomechanical advantages; however, the effect of this expanded prosthetic inventory has yet to be investigated clinically. This study seeks to determine whether prosthetic variety has led to better outcomes, has led to similar outcomes facilitating joint reconstruction, or created any unanticipated complications.Methods: One hundred sixty primary total shoulder arthroplasties were performed for osteoarthritis. Patients received 52 standard, 60 eccentric, and 48 offset humeral heads. Head geometry was selected intraoperatively during trialing based on a complementing relationship to the glenoid throughout a near-normal range of motion. Patients had 2 years of follow-up or follow-up until reoperation (mean, 4.7 years; range, 0.8-8.3 years).Results: Mean pain scores decreased from 4.5 to 1.9 on a 5-point scale (P < .001), mean elevation increased from 94° to 150°, mean external rotation increased from 22° to 57° (P < .001), larger lucent lines (≥1.5 mm) or change in glenoid position occurred around 19 components, and survivorship was 98% (95% confidence interval, 97%-100%) at 1 year and 98% (95% confidence interval, 95%-100%) at 5 years. No difference among head configurations was found for any of these outcomes.Conclusions: Evolution of designs has provided options to more accurately re-create anatomy including changes caused by osteoarthritis. At the length of follow-up in this study, clinical outcomes, radiographic performance, and survivorship are equivalent when applying these humeral head variations, and no special complications have developed.

Mid- to long-term follow-up of total shoulder arthroplasty using a keeled glenoid in young adults with primary glenohumeral arthritis

Patrick J. Denard, Patric Raiss, Boris Sowa, Gilles Walch — 2013-01-11

Background: The purpose of this study was to examine the mid- to long-term functional outcome and implant survival of total shoulder arthroplasty (TSA) in adults aged 55 years or younger with primary glenohumeral arthritis. The hypothesis was that TSA would lead to improvement in functional outcome but that implant survival would decline between 5 years and 10 years postoperatively.Materials and methods: Between 1992 and 2004, 52 TSAs were implanted in 8 centers for primary glenohumeral arthritis in patients aged 55 years or younger. Minimum follow-up of 5 years was available in 50 patients at a mean of 115.5 months postoperatively. Kaplan-Meier survivorship analysis was performed, and clinical outcome was assessed.Results: After TSA, adjusted Constant scores improved from 37.0% to 73.4% and forward flexion improved from 97° to 128° (P < .001). The adjusted Constant score was 80.0 in patients free of revision of the glenoid compared with 43.6 in the group requiring revision of the glenoid (P < .001). Survivorship of the glenoid component with revision surgery for glenoid loosening as the endpoint was 98% (95% confidence interval, 89.4%-100%) at 5 years and 62.5% (95% confidence interval, 40.6%-81.2%) at 10 years. Factors associated with survival of the glenoid included anatomic humeral component positioning and a compaction glenoid preparation technique.Conclusions: At 5 years' follow-up, TSA leads to improvement in functional outcome and a satisfactory implant survival rate of 98% in young adults with primary glenohumeral arthritis. However, the 10-year survival rate of TSA was only 62.5% in patients aged 55 years or younger at the time of surgery.

True anteroposterior (Grashey) view as a screening radiograph for further imaging study in rotator cuff tear

Kyoung Hwan Koh, Kye Young Han, Young Cheol Yoon, Seung Won Lee, Jae Chul Yoo — 2013-01-14

Background: Although findings of conventional radiography seem nonspecific, it is still the first imaging modality used to evaluate patients with rotator cuff tears. The purpose of this study is to determine whether the true anteroposterior (AP) view of the glenohumeral (GH) joint (the thorax is rotated to the affected shoulder for 35°-45°) is more sensitive than the conventional shoulder AP view (the beam and cassette are perpendicular to the torso but oblique to the glenohumeral joint) in terms of detecting rotator cuff tears.Materials and methods: Intermixed GH AP and conventional AP views of 160 consecutive shoulders, which were repaired by arthroscopic surgery, were reviewed in a blinded fashion. The detection rate of 5 pathognomonic signs for rotator cuff tear were determined by use of both radiographs: greater tuberosity (GT) sclerosis, GT osteophyte, subacromial (SA) osteophyte, GT cyst, and humeral head osteophyte. An additional comparison according to the tear size was performed.Results: The detection of all radiographic findings was significantly greater on the GH AP view than on the conventional AP view (P < .001 for GT sclerosis, P = .003 for GT osteophyte, P = .013 for GT cyst, P < .001 for SA osteophyte, and P = .002 for humeral head osteophyte). In subgroup analysis by tear size, GT sclerosis was identified significantly more on the GH AP view for all tear sizes, GT osteophytes showed a higher detection rate, especially in medium-sized tears, and SA osteophytes showed a higher detection rate in medium and large to massive tears.Conclusion: The GH view is more sensitive than the conventional AP view for detecting pathognomonic findings of rotator cuff tear. In particular, the superiority of the GH AP view in detecting abnormal radiographic findings seemed prominent in medium-sized tears.

The “bicipital aponeurosis flex test”: evaluating the integrity of the bicipital aponeurosis and its implications for treatment of distal biceps tendon ruptures

Amr ElMaraghy, Moira Devereaux — 2013-05-08

Background: One mitigating factor in the accurate diagnosis of complete distal biceps tendon ruptures (DBTR) is the integrity of the bicipital aponeurosis (BA). Current orthopedic literature lacks a descriptive means of evaluating the integrity of the BA in the presence of distal biceps injury.Methods: A consecutive cohort of 17 patients with suspected DBTR was examined. The hook test, passive forearm pronation test, and the biceps crease interval (BCI) test were performed as part of the overall clinical examination to assess the integrity of the distal tendon. The biceps crease ratio (BCR), a component of the BCI test, was used as an objective measure of distal tendon retraction. Integrity of the BA was assessed using the “BA flex test.” The status of the distal tendon and BA were confirmed intraoperatively.Results: Sixteen patients had complete rupture of the distal biceps tendon. One had a high-grade partial thickness tear. The BA remained intact in 59%. Application of the BA flex test resulted in 100% sensitivity and 90% specificity, with overall diagnostic accuracy of 94%. Despite complete DBTR, there was a significant difference in the amount of distal tendon retraction (P = .012) between those with the BA intact (median BCR, 1.5, interquartile range, 1.3-1.9) and those where the BA was absent (median BCR, 2.2, interquartile range, 1.7-2.6).Conclusion: Evaluating the integrity of the BA can help to inform evaluation and treatment of DBTR, especially when visible or palpable alterations in biceps contour and proximal tendon migration are absent or equivocal.

Does cubitus varus cause morphologic and alignment changes in the elbow joint?

2013-04-08

Background: In cubitus varus after pediatric supracondylar fracture, late development of trochlear deformity causing additional varus angulation and joint misalignment relating to late complications of the tardy ulnar nerve palsy or posterolateral rotatory instability have been suggested. However, it is unclear whether these morphologic and alignment changes of the elbow joint occur in cubitus varus. The object of this study was to investigate morphologic changes of the bones and alignment changes of the elbow joint in longstanding cubitus varus using 3-dimensional computer bone models created from computed tomography data.Materials and methods: We studied 14 patients with longstanding cubitus varus after pediatric supracondylar fractures. Three-dimensional bone models of the bilateral humerus, radius, and ulna were created from computed tomography data. We compared the morphology and alignment of the elbow joint between the affected side and contralateral unaffected side.Results: The posterior trochlea, distal part of the lateral capitellum, diameters of the radial head, and articular surface of the ulna in cubitus varus were larger than those of the contralateral elbow. In the ulna, the convex portion of the trochlear notch shifted laterally in cubitus varus. Joint alignment in cubitus varus was affected by a shift of the ulna to a more distal and medial position with external rotation and flexion.Conclusions: In longstanding cubitus varus, the morphology and alignment of the elbow joint are observed to differ from those of the normal side.

Characterization of wear debris in total elbow arthroplasty

2013-04-12

Background: The purpose of this study was to evaluate wear debris in periprosthetic tissues at the time of revision total elbow arthroplasty. Polyethylene, metallic, and bone cement debris were characterized, and the tissue response was quantified.Materials and methods: Capsular and medullary tissue samples were collected during revision surgery. Polyethylene debris was characterized by scanning electron microscopy after tissue digestion. The concentrations of metal and cement debris were quantified by inductively coupled plasma mass spectrometry. Tissue response was graded with a semiquantitative histologic method.Results: Polyethylene particle size varied from the submicron range to over 100 μm. The mean diameter ranged from 0.6 μm to about 1 μm. Particles in the synovial tissues were larger and less abundant than those in tissues from the medullary canal. Cement, titanium alloy, and low levels of cobalt-chrome debris were also present, with cement predominating over metal debris. Histiocyte response was associated with small polyethylene particles (0.5-2 μm), and giant cells were associated with large polyethylene particles (>2 μm). Histiocyte scores positively correlated with the polyethylene particle number and the presence of metal.Discussion: We have shown that periprosthetic tissues of total elbow patients who have undergone revision for loosening and osteolysis contain polyethylene, cement, and metal debris. Although the polyethylene particles were of a size and shape that have been previously shown to result in activation of phagocytic cells, osteolysis after total elbow arthroplasty is a multimodal process. Because of the presence of multiple wear particle sources, a cause-and-effect relationship between polyethylene debris and osteolysis cannot be established with certainty.

Stress analysis of glenoid component in design of reverse shoulder prosthesis using finite element method

2013-01-14

Background: This study aims to clarify the effect of various designs of reverse shoulder prosthesis (RSP) on stress variation of its glenoid component using 2-dimensional (2D) finite element analysis (FEA). This FEA study provides future reference for the optimal design of glenoid component of RSP.Materials and methods: In this study, a 2D finite element (FE) model of human shoulder with implementation of RSP was developed by commercial FE software. The proper material properties were adopted in our model. Various design factors were simulated and all the mechanical profile data were investigated by FEA.Results: Both distal placement and increased lateral offset of glenosphere induce higher stress over glenoid-baseplate junction. Increased thickness of graft, inferiorly tilting of the baseplate, and adoption of BIO-RSA (bony increased-offset reverse shoulder arthroplasty) incur higher stresses over glenoid screws. The inferior screw attains more stress than superior screw. Maximum stress occurs at the base of inferior screw.Conclusion: Increased eccentric offset and lateral offset of glenosphere, although being able to reduce notching, may pay the penalty of significant stress concentration over glenoid and its subsequent loosening. Maximum stress occurs at the base of inferior screw elucidate the direct contact failure mode at the middle of inferior screw. This study provides an alternative tool for the optimal design of glenoid component of RSP in the future.

Glenoid implant orientation and cement failure in total shoulder arthroplasty: a finite element analysis

2013-01-14

Background: To minimize glenoid implant loosening in total shoulder arthroplasty (TSA), the ideal surgical procedure achieves correction to neutral version, complete implant–bone contact, and bone stock preservation. These goals, however, are not always achievable, and guidelines to prioritize their impact are not well established. The purpose of this study was to investigate how the degree of glenoid correction affects potential cement failure.Methods: Eight patient-specific computer models were created for 4 TSA scenarios with different permutations of retroversion correction and implant–bone contact. Two bone models were used: a homogeneous cortical bone model and a heterogeneous cortical-trabecular bone model. A 750-N load was simulated, and cement stress was calculated. The risk of cement mantle fracture was reported as the percentage of cement stress exceeding the material endurance limit.Results: Orienting the glenoid implant in retroversion resulted in the highest risk of cement fracture in a homogeneous bone model (P < .05). In the heterogeneous bone model, complete correction resulted in the highest risk of failure (P = .0028). A positive correlation (ρ = 0.901) was found between the risk of cement failure and amount of exposed trabecular bone.Conclusions: Incorporating trabecular bone into the model changed the effect of implant orientation on cement failure. As exposed trabecular bone increased, the risk of cement fracture increased. This may be due to shifting the load-bearing support underneath the cement from cortical bone to trabecular bone.

Activities of daily living with reverse prostheses: importance of scapular compensation for functional mobility of the shoulder

Alexandre Terrier, Patricia Scheuber, Dominique P. Pioletti, Alain Farron — 2013-01-14

Hypothesis: The nonanatomical design of reverse shoulder prostheses induce medial displacement of the center of rotation, impingements and may reduce the mobility of the shoulder. The aim of this study is to test the hypothesis that during activities of daily living functional mobility of the shoulder can be restored by scapular compensation.Material and methods: A numerical 3-dimensional model was developed to reproduce the movement of the scapula and humerus, during 4 activities of daily living measured experimentally. This hypothesis was tested in 4 configurations of the aequalis reverse prosthesis (standard 36-mm glenosphere, 42-mm glenosphere, lateralized 36-mm glenosphere, lateralized Bony Increased-Offset Reverse Shoulder Arthroplasty [BIO-RSA]), which were implanted in the virtual model. All impingement positions were evaluated, as the required scapular compensation to avoid impingements.Results: With the 36-mm glenosphere, impingements occurred only for rest of hand to back-pocket positions. The 42-mm partly improved the mobility. The 2 lateralized glenospheres were free of impingement. When impingements occurred, the scapular compensation was less than 10°.Conclusion: Most reverse prostheses impingements reported in clinical and biomechanical studies can be avoided, either by scapular compensation or by a glenosphere lateralization. After reverse shoulder arthroplasty, a fraction of the mobility of the gleno-humeral is transferred to the scapulo-thoracic joint.

Improving glenoid-side load sharing in a virtual reverse shoulder arthroplasty model

Phillip T. Nigro, Sergio Gutiérrez, Mark A. Frankle — 2013-01-14

Background: The goal of glenoid fixation in reverse shoulder arthroplasty (RSA) is to provide a stable environment to allow bony ingrowth into the baseplate. When this does not occur, eventual baseplate failure is likely. This study aims to determine the additional implant–bone contact achieved when the glenosphere undersurface is in contact with the glenoid and if this increase in implant–bone contact improves stability through load sharing with respect to baseplate fixation. We hypothesize that substantial increases in contact area are possible and that this increased contact area will improve baseplate stability through load sharing.Methods: A computer-assisted design program was used to create 3-dimensional models of 7 currently available RSA devices. Total implant–bone contact area was compared in 2 conditions: (1) baseplate flush with bone and no additional glenosphere contact, or (2) baseplate and glenosphere undersurface in contact with bone. Next, finite element models were created from a commercially available system. Micromotion and stress were computed for each size of implant in the 2 conditions.Results: All devices tested can achieve increased total contact area when the glenosphere is in contact with bone. Stress and micromotion were reduced when comparing condition 2 with condition 1 in all sizes of one commercially available system. The average micromotion decreased 37%, from 98.04 to 61.97 μm. Larger glenospheres experienced a greater reduction in micromotion. Likewise, average von Mises stress decreased 26%, from 3.29 to 2.42 MPa.Conclusion: Increasing glenosphere size and allowing glenosphere undersurface contact increased overall implant–bone contact area and baseplate stability.

The impact of scapular notching on reverse shoulder glenoid fixation

2013-01-18

Background: Scapular notching is a well-documented complication of reverse shoulder arthroplasty. The effect of scapular notching on glenoid fixation is unknown.Materials and methods: This study dynamically evaluated reverse shoulder glenoid baseplate fixation and assessed the effect of scapular notching on fixation in composite scapulae. A cyclic test was conducted to simulate 55° of humeral abduction in the scapular plane as a 750-N axial load was continuously applied to induce a variable shear and compressive load. Before and after cyclic loading, a displacement test was conducted to measure glenoid baseplate displacement in the directions of the applied static shear and compressive loads.Results: For the scapulae without a scapular notch, glenoid baseplate displacement did not exceed the generally accepted 150-μm threshold for osseous integration before or after cyclic loading in any component tested. For the scapulae with a scapular notch, glenoid baseplate displacement exceeded 150 μm in 2 of the 7 samples before cyclic loading and in 3 of the 7 samples after cyclic loading. The average pre-cyclic glenoid baseplate displacement in the direction of the shear load was significantly greater in scapulae with a scapular notch than those without a scapular notch both before (P = .003) and after (P = .023) cyclic loading.Conclusions: Adequate glenoid baseplate fixation was achievable in most cases in scapulae with a severe scapular notch; however, the fact that this micromotion threshold was not met in all scapulae with a notch is concerning and implies that severe notching may play a role in initial glenoid baseplate stability.

Is failure of tuberosity suture repair in hemi-arthroplasty for fracture mechanical?

2013-01-21

Background: Tuberosity suture repair in hemiarthroplasty for fracture carries risk of malunion giving poor results. Is failure mechanical or biochemical? We investigated the mechanical aspect with repetitive loading in cadaveric repairs.Materials and methods: Tests were carried out in line with U.K. Human Tissue Authority regulations. A 4-part fracture was created in 8 cadaver shoulders by osteotomizing the tuberosities. A standard hemiarthroplasty implant was cemented in at correct height and retroversion, and standardized repairs applied. Initial firmness of repair was confirmed by attempting to manually displace the tuberosities with a forceps in multiple planes. All pre-stress tests showed 0 mm movement. Repairs were then subjected to cyclical tension on the cuff musculature and simultaneous gleno-humeral motion for 8000 cycles. The tuberosities were reprobed with a forceps to record any movement.Results: Defining repair failure as the ability to manually displace a tuberosity more than 3 mm, every specimen failed: 100% failure (exact 95% confidence interval 65.2-100% due to sample size). Movements of at least 1 cm were commonly observed. The sutures were loose but had never snapped. Sutures were noted to dig into the tendon and cut partially through bone. Collapse of cancellous bony volume led to looseness and migration of the sutures.Conclusion: Suture repair of tuberosities has mechanical weaknesses; failure may be a mechanical phenomenon.

Biomechanical evaluation of a coracoclavicular and acromioclacicular ligament reconstruction technique utilizing a single continuous intramedullary free tendon graft

2013-01-14

Background: Reconstruction of only the coracoclavicular (CC) ligaments may restore superior-inferior (S-I) but not anterior-posterior (A-P) stability of the acromioclavicular (AC) joint. Concomitant reconstruction of both the AC and CC ligaments may more reliably restore intact biomechanical characteristics of the AC joint.Methods: Ten matched pairs of shoulders were utilized. Five specimens underwent CC ligament reconstruction while an equal number underwent combined AC and CC ligament reconstruction utilizing an intramedullary tendon graft. Each of the reconstructions was compared with the intact contralateral control. Translational and load to failure characteristics were compared between groups.Results: No difference was found in S-I translation between intact specimens and CC-only reconstructions (P = .20) nor between intact specimens and AC/CC reconstructions (P = .33) at 10 Newton (N) loads. Significant differences were noted in A-P translation between intact specimens and CC-only reconstructions (P < .001) but no difference in A-P translation between intact specimens and AC/CC reconstructions (P = .34).Conclusion: The A-P and S-I translational biomechanical characteristics of the AC joint were restored using the new technique described. Reconstruction of the CC ligaments only (versus AC/CC combined) led to significantly increased translational motion in the A-P plane as compared to intact control specimens.

The effect of simulated scapular winging on glenohumeral joint translations

2013-01-14

Hypothesis: In this study, we aim to test whether scapular winging results in a significant change in glenohumeral translation in the initial phase of the throwing motion.Methods: Six shoulders underwent an abbreviated throwing motion (ATM) from late cocking to the end of acceleration by use of a validated robotic system. The intact specimens were tested to establish a baseline. The position of the scapula was then affected to simulate scapular winging by placing a cylindrical wedge under the inferior angle of the scapula, and the ATM was performed again. For both conditions, the average glenohumeral translations and scapular rotations were plotted over time to calculate the area under the curve, as a representative of the overall glenohumeral translations and scapular rotations observed during the ATM.Results: Throughout the motion, the winged scapulae showed, on average, 7.7° more upward rotation, 1.6° more internal rotation, and 5.3° more anterior tipping as compared with the baseline. The scapular position relative to the hanging arm was significantly different between the baseline and scapular winging conditions in all arm positions, except for maximal external rotation and the neutral position. Comparing the area under the curve at baseline and with scapular winging indicated that scapular winging significantly increased anterior translation of the glenohumeral joint whereas translation in the superior/inferior and medial/lateral directions did not result in a change in translation.Discussion: These results may suggest a more important role of abnormalities in scapular position in predisposing throwing athletes to shoulder injuries of the anterior capsulolabral structures and consecutive glenohumeral instability.

Sternoclavicular joint surgery: how far does danger lurk below?

2013-01-17

Background: Surgical stabilization of the sternoclavicular joint (SCJ) is infrequent, and cardiothoracic surgery assistance is often recommended. Patient safety and surgeon efficiency may be improved by greater understanding of the anatomic relationships near the SCJ. The purpose of this study is to determine the distances from the SCJ to critical structures in the superior mediastinum.Materials and methods: Distances from the posterior SCJ to adjacent mediastinal structures were recorded using contrast computed tomography scans of 49 consecutive patients. Patient sex, height, body mass index, side, age, and thickness of the sternum and medial clavicle were also recorded.Results: The mean distance to the nearest anatomic structure deep to the clavicular region of the SCJ was 6.6 mm and was 12.5 mm for the sternal region. The clavicle was an average thickness of 18 mm, and the sternum was an average thickness of 17 mm. The closest structure was the brachiocephalic vein. An artery was identified as the closest structure in 21.2% of patients. Distance differences between the right and left sides were noted, but sex had no bearing on distance to structures.Conclusion: Multiple mediastinal structures are close to the SCJ. The most frequent structure at risk of injury deep to the SCJ is the brachiocephalic vein. Such knowledge may improve patient safety.

Value-based shoulder surgery: practicing outcomes-driven, cost-conscious care

Eric M. Black, Laurence D. Higgins, Jon J.P. Warner — 2013-05-08

Background: Pathology of the shoulder contributes significantly to the increasing burden of musculoskeletal disease. Currently, there exists high variability in the nature and quality of shoulder care, and outcomes and cost reporting are not uniform. Value-based practice aims to simultaneously maximize outcomes and minimize costs for given disease processes.Methods: The current state of the shoulder care literature was examined with regards to cost and outcomes data, initiatives in streamlining care delivery, and evidence-based practice improvements. This was synthesized with value-based care theory to propose new avenues to improve shoulder care in the future.Conclusion: The treatment of shoulder disorders is ideal for the value-based model but has been slow to adopt its principles thus far. We can begin to advance value-based practices through (1) the universal reporting of outcomes and costs, (2) integrating shoulder care across provider specialties, and (3) critically analyzing data to formulate best practices.

A comprehensive classification of proximal humeral fractures: HGLS system

2013-01-14

Background: This study assessed the intraobserver and interobserver reliability of a binary classification system using an easy-to-remember acronym (the HGLS system—based on the reappraisal of Codman's description by Hertel et al) and compared it with the AO and Neer systems.Materials and methods: Forty-seven proximal humeral fractures in 47 patients treated at the Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia, were identified in the period from July 2007 until January 2008. Fractures of the proximal humerus were examined with anteroposterior, lateral, and axillary radiographs. Three independent reviewers classified the fractures using the AO, Neer, and HGLS systems. Reclassification of the same fractures was undertaken after a 6-month interval, and interobserver and intraobserver correlation, by use of the κ statistic, was calculated for all 3 classification systems.Results: The mean age of patients was 64.5 years (range, 16-95 years). The interobserver correlations for the AO system (κ value, 0.47) and Neer system (κ value, 0.44) were graded as poor and were consistent with the values of previously published studies. The HGLS classification showed good interobserver agreement for all 3 examiners at the first interpretation (κ value, 0.73) and second interpretation (κ value, 0.61). Good intraobserver agreement after a 6-month period was also seen for the HGLS classification (κ values, 0.87-0.92) compared with the AO system (κ, 0.61-0.71) and Neer system (κ, 0.42-0.77).Conclusion: The HGLS system provided a more reliable description of fractures of the proximal humerus compared with the Neer and AO systems. Further studies are necessary to assess the validity of the HGLS system.

Utility and complications of long-stem humeral components in revision shoulder arthroplasty

Christopher J. Owens, John W. Sperling, Robert H. Cofield — 2013-01-24

Background: Currently, there is little information on the benefits and problems associated with long-stem humeral components in shoulder arthroplasty. This study examined the frequency of use, indications, complications, and security of fixation using a long-stem humeral component in revision shoulder arthroplasty.Materials and methods: Eighty revision shoulder arthroplasties were monitored clinically for at least 2 years or until repeat revision surgery. The primary indications for use of an intermediate or long stem were proximal bone loss in 40, nonunion in 14, a malpositioned previous stem with bone loss in 10, an acute intraoperative fracture in 7, an acute preoperative periprosthetic fracture in 5, diaphyseal bone loss in 2, and a box-shaped osteotomy to remove a well-fixed stem in 2. Clinical follow-up was an average of 5.9 years, and radiographic follow-up was an average of 4.7 years.Results: Intraoperative complications included fracture removing the previous stem in 5, a cortical perforation in 6, and cement extrusion in 7. Late complications included fracture nonunion in 5, deep infection in 2, and component loosening in 1. One component met criteria to be considered radiographically “at risk” for clinical loosening.Conclusions: Long-stem humeral components are useful to obtain secure fixation in healthy bone in revision shoulder arthroplasty in patients with proximal bone loss, diaphyseal fracture, or a previously malpositioned stem. Complications are frequent, and caution should be taken to avoid intraoperative fractures, distal cortical perforation, or cement extrusion. These components are at low risk for loosening.

Biomechanical evaluation of augmentation of suture-bridge supraspinatus repair with additional anterior fixation

2013-01-18

Background: Studies have recently focused on evaluating the ability of the supraspinatus repair to withstand rotational loads. Other studies have focused on the importance of minimizing gap formation to avoid decreased healing and failure of repair. The objective of this study was to use a loading model that incorporates external rotation to biomechanically evaluate augmenting a suture-bridge technique for supraspinatus repair with an additional anterior fixation.Methods: Eight matched cadaveric shoulder pairs were randomized to 2 different types of repairs after a simulated supraspinatus tear. One group received a standard suture-bridge technique, and the other underwent a suture-bridge repair with an additional anterior fixation consisting of a 4.5-mm suture anchor. A custom apparatus was used to test all specimens, allowing for dynamic external rotation from 0° to 30° during loading. Cyclic loading was performed for 30 cycles from 0 to 90 N, followed by load to failure using a materials-testing machine.Results: No differences were found in linear stiffness, yield load, ultimate load, and energy absorbed for load to failure between the 2 groups (P > .05). There was a reduction in anterior gapping at ultimate load between the anterior augmentation repair group (6.4 ± 3.1 mm) and the standard suture bridge (9.4 ± 2.8 mm; P = .037).Conclusion: There does not appear to be a biomechanical advantage with the addition of an anterior suture augmentation of a suture bridge for a supraspinatus repair. However, using an anterior augmentation for a suture bridge prevents gap formation at ultimate load in a biomechanical, dynamic external rotation model.

Open repair of an acute latissimus tendon avulsion in a Major League Baseball pitcher

2013-05-23

Latissimus dorsi (LD) avulsion injuries are rare injuries most commonly diagnosed in competitive athletes. The LD muscle originates from the thoracic spine, thoracolumbar fascia, and iliac crest, converging toward the axilla to insert between the pectoralis major and teres major tendons, just medial to the bicipital groove of the proximal humerus. Functionally, the latissimus adducts, internally rotates, and extends the humerus. It also acts to depress the arm against resistance, compress the inferior scapula when the arm is elevated, and pull the trunk upward and forward when the arms are fixed.

Risk factors in idiopathic adhesive capsulitis: a case control study

2013-01-28

Background: The etiology of idiopathic adhesive capsulitis (IAC) of the shoulder is poorly understood. In this case control study, we examine potential risk factors for the development of IAC.Methods: Consecutive patients who presented to the senior author with IAC between 2000 and 2009 were included retrospectively in this case control study. Complete data were available for 87 patients. An age- and sex-matched group of 176 patients who presented to the same practice during the same time period with non-shoulder related orthopedic complaints were recruited as the control group. Health records and patient-completed questionnaires were utilized to identify comorbidities and other risk factors.Results: Bivariate analyses demonstrated that diabetes, hypothyroidism, a lower body weight, a lower body mass index (BMI), and a positive family history of IAC were all risk factors for IAC. Diabetes, BMI, and positive family history of IAC remained independent variables with multivariate logistic regression analyses. There was a trend towards increased incidence of Dupuytren's disease in those with IAC, but this was not statistically significant. With regard to racial predilection, being born in the British Isles or having parents/grandparents born in the British Isles were risk factors for IAC.Conclusion: We confirm diabetes as an independent predictor of IAC. In addition, we identify a possible racial predilection for the development of IAC. Future research is needed to confirm whether a specific genetic component or environmental factors is responsible.

Regarding “Risk factors for development of heterotopic ossification of the elbow after fracture fixation”

Liang Ding, Zhimin He, Haijun Xiao, Feng Xue — 2013-05-24

We read the study reporting risk factors for development of heterotopic ossification (HO) of the elbow after fracture fixation. The information including “age, gender, medical comorbidities, AO fracture classification, presence of a coronoid fracture, elbow dislocation, open fracture, closed-head injury, time to definitive surgical treatment, surgical approach, fixation type, ulnar nerve transposition, lateral collateral ligament (LCL) repair, range of motion at final follow-up, total number of surgeries, and size and location of HO” was extracted from the medical record and radiographic review by the authors. There is no mention about whether the patients had spinal cord injuries (SCIs). However, SCI can increase the risk of development of HO. Neurogenic HO is the ectopic formation of lamellar bone in non-osseous tissues after SCI. In SCI patients, the incidence of HO ranges from 10% to 53% depending on the study design, the methods of detection (radiologically or by clinical symptoms), and the diagnostic criteria used. Neurogenic HO always occurs below the level of the SCI, most commonly at the hip (70%-97%). Other body segments including the knee, elbow, shoulder, hand, and spine (in decreasing incidence) may be involved.

Response to letter to editor regarding “Risk factors for development of heterotopic ossification of the elbow after fracture fixation”

Geoffrey D. Abrams, Michael J. Bellino, Emilie V. Cheung — 2013-04-29

We read with interest the letter raising the issue of increased prevalence of heterotopic ossification (HO) in patients with spinal cord injuries. We agree with the authors of the letter that spinal cord injury significantly increases the risk of extremity HO after trauma. In our investigation, we did collect information related to neurologic injury. The study states that “patients were defined as having a closed-head injury when the diagnosis was included in the medical record and there was documentation of neurologic injury not due to peripheral nerve injury.” Clearer terminology should have been used on our part because any neurologic injury that was not due to peripheral nerve injury was recorded as “closed-head injury.” Both closed-head injuries and spinal cord injuries were included in this category.

Regarding “Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance?”

Tomoyuki Kawada — 2013-05-09

I have read the article by Cho et al. They concluded in their cross-sectional study that shoulder pain for 3 months or longer was closely related to sleep disturbance by the Pittsburgh Sleep Quality Index.

In Reply

Chul-Hyun Cho, Ilseon Hwang — 2013-04-29

We read the letter from Dr Tomoyuki Kawada regarding “Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance?” by Cho et al and are thankful for the opportunity to submit a response.

2013-07-01

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2013-07-01

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2013-07-01

Journal of Shoulder and Elbow Surgery

Isometric strength, range of motion, and impairment before and after total and reverse shoulder arthroplasty

Hemiarthroplasty vs total shoulder replacement for rotator cuff intact osteoarthritis: how do they fare after a decade?

The role of eccentric and offset humeral head variations in total shoulder arthroplasty

Mid- to long-term follow-up of total shoulder arthroplasty using a keeled glenoid in young adults with primary glenohumeral arthritis

True anteroposterior (Grashey) view as a screening radiograph for further imaging study in rotator cuff tear

The “bicipital aponeurosis flex test”: evaluating the integrity of the bicipital aponeurosis and its implications for treatment of distal biceps tendon ruptures

Does cubitus varus cause morphologic and alignment changes in the elbow joint?

Characterization of wear debris in total elbow arthroplasty

Stress analysis of glenoid component in design of reverse shoulder prosthesis using finite element method

Glenoid implant orientation and cement failure in total shoulder arthroplasty: a finite element analysis

Activities of daily living with reverse prostheses: importance of scapular compensation for functional mobility of the shoulder

Improving glenoid-side load sharing in a virtual reverse shoulder arthroplasty model

The impact of scapular notching on reverse shoulder glenoid fixation

Is failure of tuberosity suture repair in hemi-arthroplasty for fracture mechanical?

Biomechanical evaluation of a coracoclavicular and acromioclacicular ligament reconstruction technique utilizing a single continuous intramedullary free tendon graft

The effect of simulated scapular winging on glenohumeral joint translations

Sternoclavicular joint surgery: how far does danger lurk below?

Value-based shoulder surgery: practicing outcomes-driven, cost-conscious care

A comprehensive classification of proximal humeral fractures: HGLS system

Utility and complications of long-stem humeral components in revision shoulder arthroplasty

Biomechanical evaluation of augmentation of suture-bridge supraspinatus repair with additional anterior fixation

Open repair of an acute latissimus tendon avulsion in a Major League Baseball pitcher

Risk factors in idiopathic adhesive capsulitis: a case control study

Regarding “Risk factors for development of heterotopic ossification of the elbow after fracture fixation”

Response to letter to editor regarding “Risk factors for development of heterotopic ossification of the elbow after fracture fixation”

Regarding “Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance?”

In Reply

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