Journal of Shoulder and Elbow Surgery

Does scapular dyskinesis affect top rugby players during a game season?

Takayuki Kawasaki, Jun Yamakawa, Takefumi Kaketa, Hideo Kobayashi, Kazuo Kaneko — 2012-03-23

Background: Scapular dyskinesis represents a considerable risk of shoulder injury to overhead athletes; however, there is a shortage of detailed epidemiologic information about scapular dyskinesis among the participants in collision sports.Purpose: To describe the incidence and relationship of scapular dyskinesis to shoulder discomfort and variables related to the shoulder in top rugby players.Methods: One hundred twenty top rugby football players in Japan were evaluated by means of questionnaires, physical examinations, and a video analysis during their preseason. Data were assessed by a logistic regression analysis calculating odds ratios. The primary outcome was processed to assess the relationship between scapular dyskinesis and other variables at the preseason. The secondary outcome was processed to assess an influence of scapular dyskinesis to shoulder discomfort during their regular season that were reassigned by second questionnaires.Results: Scapular dyskinesis was identified in 33 (32%) shoulders, and type III was prominent. Scapular dyskinesis was significantly associated with shoulder discomfort (OR [odds ratio] = 4.4), and was also associated with variables of the affected shoulder. In addition, the players with asymptomatic scapular dyskinesis at the preseason would have high incident with shoulder discomfort during their regular season (OR = 3.6).Conclusions: Scapular dyskinesis was associated significantly with both subjective and objective symptoms of the affected shoulder. These appearances may be of particular relevance in the early screening of chronic shoulder disorders in the rugby population. Further study to investigate and evaluate its reliability is needed to characterize its impact on the participants in collision sports.

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

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

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

Does hyaluronate injection work in shoulder disease in early stage? A multicenter, randomized, single blind and open comparative clinical study

Yang-Soo Kim, Jin-Young Park, Chang-Soo Lee, Seung-Jun Lee — 2012-02-27

Background: This study assessed the hypothesis that injection of high-molecular weight hyaluronate in the treatment of subacromial impingement syndrome is effective and safe, compared with corticosteroid injection in the shoulder joint.Methods: One hundred five patients were allocated randomly into 2 groups: 1 group was injected once a week for 3 weeks with hyaluronate and the other group was injected once with corticosteroid. All injections were guided to the subacromial space by an ultrasonogram. Eighty patients were followed up for 12 weeks after the injection: 38 patients in the hyaluronate group and 42 patients in the corticosteroid group. The functional outcome was measured using the American Shoulder and Elbow Surgeons standardized shoulder assessment form (ASES).Results: The Visual Analogue Scale (VAS) score at 12 weeks was decreased significantly from 58.6 ± 19.3 to 24.6 ± 23.1 in the hyaluronate group (P < .0001) and from 57.2 ± 19.9 to 36.9 ± 26.5 (P < .0001) in the corticosteroid group. There was a significant difference in the VAS score between the hyaluronic acid group and corticoid group (P = .0180) at 12 weeks. The functional ASES scores in the hyaluronate and corticosteroid groups were increased from 17.6 ± 4.8 to 22.4 ± 6.5 and from 17.3 ± 4.9 to 21.7 ± 5.8, respectively, at 12 weeks (P = .4825). There was no difference in the number of patients requiring rescue medication between the hyaluronate group and corticosteroid group at 12 weeks (P = .9254).Conclusion: A subacromial hyaluronate injection to treat impingement syndrome produces similar pain and functional improvement to corticosteroid at a short-term follow-up.

The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs

2012-06-01

Background: Superior labrum anterior-posterior (SLAP) lesions of the shoulder that require surgical repair are relatively uncommon. However, recent observations suggest that there may be a rise in the incidence of SLAP lesion repair.Materials and methods: The Statewide Planning and Research Cooperative Systems (SPARCS) database from the New York State Department of Health was used to acquire data for all outpatient ambulatory surgery procedures that were performed in New York State from 2002 to 2010. The data were reviewed and analyzed to compare the incidence of arthroscopic SLAP lesion repairs relative to other outpatient surgical procedures.Results: Within New York State, from 2002 to 2010, the number of all ambulatory surgical procedures increased 55%, from 1,411,633 to 2,189,991. Correspondingly, the number of ambulatory orthopedic procedures increased 135%, from 118,126 to 278,136. In comparison, the number of arthroscopic SLAP repairs increased 464%, from 765 to 4,313 (P < .0001). This represented a population-based incidence of 4.0/100,000 in 2002 and 22.3/100,000 in 2010. The mean age of patients undergoing arthroscopic SLAP repair in 2002 was 37 ± 14 years. The mean age in 2010 was 40 ± 14 years (P < .0001).Conclusions: The data suggest a substantial increase in the number of arthroscopic SLAP repairs that is significantly more rapid than the rising rate of outpatient orthopedic surgical procedures. In addition, there is a significant increase in the age of patients who are being treated with arthroscopic SLAP repairs.

Surgical management of uncomplicated midshaft clavicle fractures: a comparison between titanium elastic nails and small reconstruction plates

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

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

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

2011-12-23

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

A comparison of the degree of retraction of full-thickness supraspinatus tears with the Goutallier grading system

Simon M. Thompson, Peter Reilly, Roger J.H. Emery, Anthony M.J. Bull — 2011-11-11

Background: Tears of the supraspinatus are common and incompletely understood. The degree of fatty infiltration into the muscle is perceived to be a determining factor of successful surgical repair and postoperative function. It is the hypothesis of this study that the degree of central tendon retraction (CTR) as seen on magnetic resonance imaging corresponds to the amount of fatty infiltration classified according to the Goutallier grading system.Materials and methods: Magnetic resonance imaging scans of the supraspinatus were reviewed in 2 identifiable groups: 143 scans with no tear (NT) and 148 scans with a full-thickness tear (FTT) and CTR. The degree of CTR and the corresponding Goutallier grade were measured. The difference in Goutallier grade between the NT and FTT groups was measured with the Mann-Whitney test. The relationship between Goutallier grade and increasing amount of CTR was described by use of Spearman rank correlation. Studying the difference between the Goutallier grades and CTR was achieved by use of Mann-Whitney tests.Results: Of NT scans, 100% showed Goutallier grade 0 or 1. Among FTT scans, 2 showed grade 0, 21 showed grade 1, 35 showed grade 2, 14 showed grade 3, and 76 showed grade 4. The difference was statistically significant (P < .001) between the Goutallier grade 3 and 4 scans, and the degree of Goutallier grade increased with increasing CTR (P < .001).Conclusion: Fatty infiltration can be directly linked to CTR and, as such, may help to determine surgical intervention between groups.

Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures

2012-02-10

Background: Recent studies have detailed the significance of indolent infections in revision shoulder arthroplasty, but little information is available to guide treatment strategies regarding patients with positive cultures without overt signs of infection. The primary purpose of this study was to determine recurrence rates of infection for patients undergoing revision shoulder arthroplasty who were not treated for infection but had positive intraoperative cultures.Materials and methods: We retrospectively reviewed the results of 17 patients undergoing revision of a failed shoulder joint replacement with at least 1 positive intraoperative culture who were not treated for infection because of limited signs of infection before or at the time of revision surgery. These patients underwent 1-stage revision surgery without an extended intravenous antibiotic regimen.Results: The recurrence rate of infection for the 17 patients was 5.9%. The most common pathogen cultured at revision surgery was Propionibacterium acnes (10 of 17 [56%]), followed by coagulase-negative Staphylococcus species (6 of 17 [35%]).Conclusion: We found that low-virulence and clinically unexpected infections treated with 1-stage revision have a low risk for recurrent infection. This study suggests that intensive antimicrobial treatment strategies may not be necessary to reduce recurrent infections in patients with positive intraoperative cultures, without overt clinical signs of infection before or during the revision surgery.

Recovery of sensory disturbance after arthroscopic decompression of the suprascapular nerve

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

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

Fate of large structural allograft for treatment of severe uncontained glenoid bone deficiency

Joseph P. Iannotti, Salvatore J. Frangiamore — 2012-02-10

Background: Structural allografts have been used for management of large defects of the glenoid. We describe a surgical technique for graft preparation and the radiographic and clinical results of a series of patients using this technique.Materials and methods: In 19 consecutive patients, a polymethyl methacrylate mold was used to shape a single graft from a fresh-frozen femoral head to press fit within the glenoid defect. We evaluated the clinical and radiographic results with a minimum 2-year follow-up or until revision to another total shoulder replacement.Results: Six patients showed more than 50% resorption of the graft. Four of these six patients also had less than 50% graft incorporation, and these findings were associated with a less favorable clinical outcome. In 3 of 6 cases in which poly-L-lactic acid bioresorbable screws were used, a significant giant cell reaction was noted at the time of revision surgery. Seven of nine patients with metal screw fixation had bent, broken, or worn screws because of graft collapse and contact with the prosthetic humeral head. Four of the five revision cases that were converted to a reverse total shoulder replacement had sufficient bone incorporation and volume of bone to allow for secure glenoid and screw fixation.Conclusion: The surgical technique described is useful in creation of a well-fitting graft. The amount of bone resorption and bone incorporation and clinical outcome have wide variability. In those cases where revision was performed with another total shoulder replacement, there was sufficient bone incorporation and sufficient bone mass to allow component fixation.

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

2012-04-20

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

Shoulder internal rotation elbow flexion test for diagnosing cubital tunnel syndrome

2012-01-05

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

Fractures of the coronoid: morphology based upon computer tomography scanning

2012-04-19

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

Effect of radial head malunion on radiocapitellar stability

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

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

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

2011-12-15

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

In vivo temperature measurement in the subacromial bursa during arthroscopic subacromial decompression

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

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

Validation of the Dutch version of the Simple Shoulder Test

2011-12-26

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

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

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

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

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

2011-12-05

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

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

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

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

Suprascapular neuropathy: what does the literature show?

2012-03-26

Suprascapular neuropathy remains a rare, albeit increasingly recognized, diagnosis. Despite its relatively low prevalence, it must be kept in the shoulder surgeon’s mind as a potential cause of shoulder pain, particularly in patients where the history, physical examination, and imaging studies do not adequately explain a patient’s symptoms or disability. Although challenging to identify, suprascapular neuropathy can be successfully treated. The current literature shows that the location and mechanism of nerve injury are the most important factors guiding management. Different treatment strategies are required, depending on the specific location and type of nerve injury. Controversy regarding if and when to perform an isolated suprascapular nerve release continues. Furthermore, no recommendations regarding suprascapular nerve release in conjunction with rotator cuff repair can be made at this time, and further research is necessary to better delineate the indications in the future.

Bilateral anterior and posterior glenohumeral stabilization using Achilles tendon allograft augmentation in a patient with Ehlers-Danlos syndrome

Salma Chaudhury, Selom Gasinu, Scott A. Rodeo — 2012-02-13

Generalized joint hypermobility is a potentially incapacitating manifestation of connective tissue disorders, the commonest of which is Ehlers-Danlos Syndrome (EDS). EDS is a phenotypically and genetically heterogeneous disorder caused by abnormal collagen synthesis and cross-linking. The cardinal manifestations of EDS consist of hyperextensible skin, joint hypermobility, dystrophic scarring, and connective tissue fragility. Joint laxity and hypermobility in EDS occurs as a consequence of increased elasticity and length of restraining structures such as joint capsules, ligaments, and tendons. In particular, patients with hypermobility-type EDS (type III) have a larger range of motion and lower level of sports activity compared with controls. Joint instability with secondary tendonitis and chronic joint pain are common sequelae. Hypermobility-type EDS patients have also been proposed to be more prone to joint instability due to altered proprioception and vibratory perception; however, a case-control study did not find any sensory variations between EDS and control patients.

Operative treatment of isolated teres major ruptures

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

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

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

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

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

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

2011-12-19

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

Spontaneous healing of Hill-Sachs lesion after arthroscopic bony Bankart repair

Jae Yoon Kim, Jae Sung Lee, Kyung Won Choi — 2012-02-27

Hill-Sachs lesions are impression fractures of the humeral head due to impaction of the posterolateral aspect of an anteriorly dislocated humeral head with the anterior rim of the glenoid. They are found in most patients with recurrent shoulder dislocation, and 20% to 45% of the articular surfaces are known to require additional repair procedures due to the high risk of dislocation recurrence after conventional Bankart repair.

2012-06-01

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2012-06-01

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2012-06-01

Journal of Shoulder and Elbow Surgery

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