The aim of our retrospective study is to compare infraspinatus strength and functional outcomes in patients treated with Classic Judet versus Modified Judet approach for scapular fractures. Surgical treatment of scapular fracture with posterior approach is frequently associated with infraspinatus postoperative hypotrophy. The Classic Judet approach (CJ) require the infraspinatus muscle lateral reflection. The Modified Judet approach (MJ) consists in a blunt dissection through the interval between infraspinatus and teres minor. We enrolled 20 patients with scapular neck and body fracture treated with posterior approach for lateral border plate fixation. In 11 of 20 cases we used MJ Approach and in 9 cases we used CJ approach. All fractures were classified according to AO Classification system. At the follow-up examinations patients had X-Ray assessment with Acromion Humeral Distance (AHD) measurement, clinic evaluation, active ROM examination, Constant Shoulder Score, DASH Score. Infraspinatus strength assessment was measured using a dynamometer during Infraspinatus strength test (IST) and Infraspinatus Scapular Retraction Test (ISRT). Demographic data did not significantly differ between CJ Group and MJ Group. All X-ray examinations showed fracture healing. The AHD was significantly decreased in CJ Group (p=0.006). We did not find significant differences in active ROM between MJ and CJ (p<0.05). The Constant Score and DASH score were not statistically different (p> 0.05). The IST and ISRT tests showed a mean strength statistically higher in MJ group (p=0.002). Infraspinatus ipotrophy was detected in 6 patients, 5 of CJ group and 1 of MJ group and it was strictly related to infraspinatus strength weakness in IST and ISRT (p<0.001). Infraspinatus sparing surgical approach for scapular fractures avoids infraspinatus hypotrophy and external-rotation strength weakness. We suggest to use mainly Modified Judet approach for scapular fracture and to restrict as much as possible Classic Judet approach to scapular fractures extending to medial border
Objectives:Post-operative retear is the most common surgical complication following rotator cuff repair with reported rates ranging from 11% to 94%. There have been a number of advancements in the technology and management of rotator cuff repair which may have improved retear rates. The aim of this study was to determine if there has been any improvements in rotator cuff repair integrity in our centre and, to identify any changes in the management of rotator cuff tears that may have impacted post-operative re tear rate. Methods:This observational single cohort study used running average analysis to examine 1600 consecutive patients who underwent primary arthroscopic rotator cuff repair by a single surgeon, and had cuff integrity assessed by ultrasound six months post operation. Exclusion criteria included revision rotator cuff repairs, isolated subscapularis repairs, and irreparable tears. Results:Retear rates over the course of our study ranged from 3% to 34%, with the mean retear rate being 15%. The retear rate at the commencement of our study was 18% and decreased to 5% by the end. Reductions in retear were associated with; more passive rehabilitation, more attention to post-operative abduction sling use, increased surgical team experience. Increases in retear rates were associated with; increased false positives with a more sensitive ultrasound machine and, learning curves with new equipment for surgeon and sonographer. Conclusion:A significant decrease in retear rate following arthroscopic rotator cuff repair was observed over the course of our study with the re-tear rate at the end of the study being 5%. While the study design does not allow us to directly attribute changes in retear rate to changes in management, our results suggest that less aggressive rehabilitation, abduction sling use and increased surgeon experience decrease postoperative retear.
We aimed to detect Cutibacterium acnes with histologic methods from intra-articular shoulder tissue specimen and to analyse whether it can be found intracellularly when taken from patients having first time shoulder surgery. Cutibacterium acnes is a mysterious member of the shoulder microbiome. It has been multiply associated with chronic postoperative complications and low-grade infections in orthopedic surgery. Still, it is unclear whether it should be either linked to skin contamination or to true deep infections. Some authors hypothesized C. acnes to be a commensal of deep, intraarticular tissues and linked it to osteoarthritis. Further, C. acnes is reported to persist in macrophages as a niche for its survival and spread. In 23 consecutive, otherwise healthy patients (17 m, 6 f; 58y), who had first time shoulder surgery and no previous shoulder injections, specimen were taken from intraarticular tissue during arthroscopic (n=11) and open (n=12) surgery. The samples were microbiologically cultivated and histologically processed using immunohistochemical staining with C. acnes specific antibodies, CD163 macrophage and ß-actin markers to identify the position of C. acnes within the cell cytoskeleton. Positional analyses were conducted with a 3D confocal laser microscopy scanner at a maximal resolution of 310nm. In 10 patients (43%) C. acnes growth was observed in microbiological culture (7 subcutanenous, 7 deep). C. acnes was detected in all tissue samples at histological analysis. In 5 tissue samples (22%, all arthroscopic), C. acnes was detected intracellularly in stroma cells and in macrophages. C. acnes can be detected intracellularly in macrophages and within stroma cells of intraarticular tissues of patients who never experienced a previous penetration of their shoulder joint. These data indicate C. acnes to be a commensal of the human shoulder joint where it persists within macrophages and stroma cells.
BACKGROUND:Although venous thromboembolism (VTE) has been studied in lower-extremity arthroplasty, there are few guidelines regarding established risk factors for VTE in total shoulder arthroplasty (TSA). With literature suggesting the VTE rate may be as high as 13%, VTE prevention and risk factors should be considered in preoperative planning. METHODS:All TSAs from 2011 through 2016 were queried from the National Surgical Quality Improvement Program database. Age, sex, body mass index, American Society of Anesthesiologists class, ethnicity, functional status, comorbidities, discharge destination, surgical indication, length of stay, and operative time were compared between patients with and without 30-day postoperative VTE. Pearson χ2 and t tests were used to assess baseline categorical and continuous variables, respectively. Multivariate logistic regression analysis was conducted to determine associated independent risk factors for VTE. RESULTS:The analysis included 13,299 patients; VTE developed in 83 patients (0.62%). Patients with VTE were older (72 years vs. 69 years) and had a longer hospital stay (3.5 days vs. 1.9 days). Compared with patients with no VTE, patients with VTE were more likely to undergo TSA for proximal humeral fractures, to be discharged to a rehabilitative center, to have a preoperative albumin level lower than 3.5 g/dL, to undergo non-elective surgery, to have an American Society of Anesthesiologists class of 3 or greater, to have a surgical-site infection develop, and ultimately to need a shoulder reoperation (all P < .05). Multivariate logistic regression analysis revealed that hypoalbuminemia (albumin level < 3.5 g/dL), an increased length of stay, and African American ethnicity were independent risk factors for VTE development. CONCLUSION:Patients with hypoalbuminemia, an increased length of stay, and African American ethnicity are at an increased risk of VTE after shoulder arthroplasty. A high index of suspicion is warranted for elderly patients with fractures who may need preoperative medical optimization.
A 37-year-old right hand–dominant gentleman who works in auto part delivery was evaluated in clinic for anterior shoulder pain. He states that several years prior to his presentation in clinic he was having insidious-onset atraumatic right shoulder pain. A magnetic resonance image (MRI) at that time demonstrated some long head of biceps tendinopathy at which point he underwent an arthroscopic rotator cuff débridement with mini-open subpectoral biceps tenodesis in 2011. After surgery, he completed extensive physical therapy but continued to have pain in the anterior axillary fold down through the medial aspect of the biceps muscle belly. He presented in 2017, 6 years after his initial operation, with severe debilitating pain starting at the subpectoral axillary fold incision site with radiation going down the arm. The pain was well localized and made worse with activity, especially resisted supination or lifting away from his body. He rated the pain approximately 5-6 of 10 and stated that his arm pain was much worse than it was before his original surgery in 2011. The pain now caused him limitations in everyday activities, which affected his work and lifestyle. He denied any numbness, tingling, motor or sensory deficits. On examination, there were well-healed portal sites and he denied any history of infection or postoperative wound healing complications. On examination, visual inspection of his bilateral shoulders demonstrated normal scapular posture. No asymmetry or gross muscle atrophy could be visualized. On the right, he had well-healed portal sites. He had approximately 150° of forward elevation on the right compared to 160° on the left. He had 55°-65° of adducted external rotation with no external rotation lag sign bilaterally and symmetric internal rotation to the thoracolumbar junction bilaterally. There was pain and point tenderness over a palpable protuberance in the axilla and next to his subpectoral incision with radiating pain into the biceps on the right side. He had no palpable tendon in the bicipital groove. There was some pain with resisted supination, but otherwise he had no strength deficits. He had a negative abdominal compression test. An MRI was obtained in an attempt to better understand the etiology of his pain and look at the position of the long head of the biceps as well as an electromyography to look for any entrapment of the musculocutaneous nerve. The MRI showed intact rotator cuff tendons without any muscular atrophy as well as what appeared to be a screw with some fluid surrounding the biceps tendon distally at the tenodesis site. Electromyography of the right arm was completely normal. At this time, the patient was offered exploration with open biceps tenotomy and removal of the enthesophyte vs. revision biceps tenodesis. The patient obtained an additional MRI that showed an enthesophyte emerging from the bone at the tenodesis site (Fig. 1). This case report details the formation of an enthesophyte at the site of subpectoral biceps tenodesis as a complication of the aforementioned surgery. We believe that the etiology of the described enthesophyte was similar to enthesophyte formation at other parts of the body, most likely a combination of traction, periosteal reaction, and trauma to the region. To our knowledge, this complication has not been documented in the literature. This patient developed pain and weakness postoperatively and presented 6 years after his original open subpectoral tenodesis. Common indications for revision tenodesis or tenotomy include persistent biceps pathology and biceps rupture1Dickens J.F. Kilcoyne K. Tintle S. Giuliani J. Schaefer R. Rue J.P. Subpectoral biceps tenodesis: an anatomic study and evaluation of at-risk structures (SS-21).Arthroscopy. 2011; 27: e40-e41https://doi.org/10.1016/j.arthro.2011.03.024Abstract Full Text PDF Google Scholar, 2Gregory J. Gochanour E. Harwood D. Sherman S. Romeo A. Clinical outcomes of revision biceps tenodesis.Int J Shoulder Surg. 2012; 6: 45-50https://doi.org/10.4103/0973-6042.96993Crossref PubMed Google Scholar, 3Heckman D.S. Creighton R.A. Romeo A.A. Management of failed biceps tenodesis or tenotomy: causation and treatment.Sports Med Arthrosc Rev. 2010; 18: 173-180https://doi.org/10.1097/jsa.0b013e3181e892c1Crossref PubMed Scopus (0) Google Scholar; however, more rare complications including musculocutaneous nerve entrapment and humeral fractures involving the subpectoral humeral drill hole have been documented.4Ma H. Heest A.V. Glisson C. Patel S. Musculocutaneous nerve entrapment.Am J Sports Med. 2009; 37: 2467-2469https://doi.org/10.1177/0363546509337406Crossref PubMed Scopus (36) Google Scholar, 7Sears B.W. Spencer E.E. Getz C.L. Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients.J Shoulder Elbow Surg. 2011; 20: e7-e11https://doi.org/10.1016/j.jse.2011.02.020Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar Most commonly, patients present with persistent pain and weakness as our patient did.5Nho S.J. Reiff S.N. Verma N.N. Slabaugh M.A. Mazzocca A.D. Romeo A.A. Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery.J Shoulder Elbow Surg. 2010; 19: 764-768https://doi.org/10.1016/j.jse.2010.01.024Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar, 6Sanders B. Lavery K.P. Pennington S. Warner J.J. Clinical success of biceps tenodesis with and without release of the transverse humeral ligament.J Shoulder Elbow Surg. 2012; 21: 66-71https://doi.org/10.1016/j.jse.2011.01.037Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar, 8Werner B.C. Evans C. Holzgrefe R. Lyons M.L. Hart J.M. Carson E.W. et al.Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of minimum 2-year clinical outcomes.Orthop J Sports Med. 2014; 2https://doi.org/10.1177/2325967114s00061Crossref Google Scholar Our recommendation is that enthesophyte formation should be considered on the differential for a patient with persistent pain and weakness after subpectoral biceps tenodesis. Postoperative imaging should be considered including either computed tomography low enough to visualize the tenodesis site or multiple views on plain radiography.
Background: Our aim was to analyze the epidemiology, etiologies, and revision options for failed shoulder arthroplasty from 2 tertiary centers. Methods: From 1993 to 2013, 542 failed arthroplasties were revised in 540 patients (65% women): 224 hemiarthroplasties (HAs, 41%), 237 anatomic total shoulder arthroplasties (TSAs, 44%) and 81 reverse total arthroplasties (RSAs, 15%). Data about patients, pathology, and reintervention procedures, as well as intraoperative data, were analyzed from our 2 local registries that prospectively captured all the revision procedures. Patients had an average follow-up period of 8.7 years. Results: The revision rate was 12.7% for HAs, 6.7% for TSAs, and 3.9% for RSAs. HAs were revised earlier (33 +/- 40 months) than RSAs (47 +/- 150 months) and TSAs (69 +/- 61 months). Glenoid failure was a major cause of reintervention: erosion in HAs (29%) or loosening in TSAs (37%) and RSAs (24%). Instability was another major cause of reintervention: 32% in RSAs, 20% in TSAs, and 13% in HAs. Humeral implant loosening led to revision in 10% of RSAs. 6% of HAs, and 6% of TSAs. Multiple reinterventions were required in 21% of patients, mainly for instability (26%) and/or infection (25%). The final implant was an RSA in 48%, especially when associated with cuff insufficiency, instability, and/or bone loss. Final reimplantation was possible in 90% of cases, with the remaining 10% treated with a resection or spacer. Conclusion: Glenoid failure and instability are the most common causes of revision. Soft-tissue insufficiency and/or infection results in multiple revisions. Surgeons must recognize all complications so that they can be addressed at the first revision operation and avoid further reinterventions. RSA was the most common final revision implant. (C) 2019 Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees.
The primary aim of the current study is to assess the structural integrity of a series of augmented RCR utilising magnetic resonance imaging (MRI), at 1-year follow up. The secondary aim is to report the functional outcome. Healing of rotator cuff tendons is still a challenge especially in the elderly population. Failure rate of rotator cuff repairs(RCR) is still high(25-70%): augment patches may provide both a structural and a biological support. Between 2014 and 2016, 45 patients with large-massive rotator cuff tears were prospectively enrolled in the study. They all underwent arthroscopic double-row RCR with extracellular porcine dermal matrix augmentation. At 1-year, an MRI scan was performed to assess integrity of the repair. Oxford Shoulder Score(OSS), Constant Score(CS) and Visual Analogue Scale(VAS) pain score were used preoperatively and at 3, 6, 12-month follow-up. Minimum follow-up: 1-year. Patients mean age was 70(53-81). MRI scans performed at 1-year showed 7 rotator cuff tears out of 34 patients(20%). Both mean CS and OSS improved postoperatively at 3,6 and 12-month, with statistically significant improvement(p<0.01) already at 3-month. Range of movement significantly improved: mean abduction improved from 95.8°(±33.3°) to 161.8°(± 21°)(p<0.05); mean forward flexion from 107°(±37°) to 165.9°(±24.3°)(p<0.05). The pain also decreased significantly postoperatively(p<0.01). No complications or adverse reactions were observed. This study showed a healing failure rate of 20%, which is low compared to what is described in the literature for standard rotator cuff of large-massive tears in similar patient age groups to ours. Augmented patches were shown to be a safe and reliable support to RCR for large-massive tears. Patients recovered good shoulder function and returned to their daily life activities with good control of pain.
Background With the historical complications when using total shoulder arthroplasty (TSA) to revise failed arthroplasties, and the success of the reverse prosthesis in the revision setting, the question arises whether revision to TSA is still a reasonable option? This systematic review examines revision to TSA and the factors associated with outcomes. Methods A systematic review was performed for studies of TSA used to revise a failed hemiarthroplasty or TSA. The primary outcome was implant failure leading to a repeat revision arthroplasty. Secondary outcomes included visual analog scale (VAS) pain scores, shoulder motion and other clinical outcomes of shoulder function. Data were pooled to generate representative frequency-weighted means. Results Thirteen studies were included, totaling 312 shoulders. Etiologies for revision included glenoid arthrosis (62%), glenoid component failure (36%), and other (2%). Of which, 39% of cases experienced complications and 12% required another arthroplasty revision. Secondary outcomes such as VAS pain, Constant, ASES and UCLA score improved, but none were statistically significant. Unsatisfactory outcomes were higher among patients with glenoid bone loss, instability, and soft tissue deficiencies. Discussion Revision to anatomic TSA can be an acceptable option in certain patients. However, the high rate of complications and glenoid loosening, makes this a limited approach for a revision to anatomic TSA procedure.
There is a paucity of information on latissimus dorsi transfer (LDT) for subscapularis insufficiency. The purpose of this study is to report the outcome of LDT to reconstruct an irreparable subscapularis tear. METHODS:Excluding patients with prior failed Latarjet procedures, we examined 56 consecutive patients who underwent open (n = 14) or arthroscopic (n = 42) LDT. The average age was 53 years (range, 23-79), and 46 patients had a prior surgery. Outcome measures included visual analog scale score for pain, range of motion (ROM), subjective shoulder value (SSV), and Constant shoulder score (CSS). RESULTS:At a mean 13-month follow-up (7-51 months), patients had significant improvements in their pain, ROM, SSV, and CSS when compared to preoperatively. At final follow-up, 26% of patients continued to have proximal migration, and 11% of patients had anterior subluxation. The patients with frank anterior escape had a higher likelihood of having proximal migration and anterior subluxation, but this was not statistically significant. Stages of arthritis did not progress. Revision surgeries included 2 patients who revised to a reverse shoulder arthroplasty for rupture of the tendon transfer. Furthermore, 3 patients had LDT ruptures but did not elect to undergo further surgery. CONCLUSIONS:LDT for irreparable subscapularis tears has the potential to lead to significant clinical improvements. Most patients improve in many of the signs of subscapularis insufficiency, including anterior and/or proximal subluxation, clinical examination maneuvers, and shoulder function. Overall, this transfer represents a reasonable option for this difficult pathology.
Background: Tranexamic acid (TXA) is commonly used in orthopedic surgery to reduce perioperative bleeding and the need for transfusion. The purpose of the study was to assess whether TXA could reduce the incidence of postoperative swelling and hematoma formation and pain and opioid use in the early postoperative period following the Latarjet procedure. Methods: A randomized controlled trial was conducted in 100 patients undergoing open Latarjet surgery for anterior shoulder instability by a single surgeon. Patients were randomized to receive either 1 g TXA or a placebo intravenously preoperatively. Outcomes measured during the perioperative period were (1) intraoperative blood loss, (2) postoperative blood loss (via drain output), (3) postoperative swelling/hematoma formation, (4) visual analog scale (VAS) score, and (5) postoperative opioid use (in morphine milligram equivalents). Results: There was no significant difference in intraoperative blood loss (60.9 vs. 68.9 mL, P = .18). However, there was significantly lower postoperative blood loss with TXA (29.6 vs. 64.9 mL, P < .01). There was a significantly lower rate of painful postoperative swelling (4% vs. 32%, P < .01). Additionally, we found a significantly lower VAS score for pain (1.7 vs. 3.0, P < .01) and significantly less postoperative opioid use (9.4 vs. 22 mg, P < .01) in the TXA group. Postoperative swelling was shown to correlate with increased pain and opioid use (P < .01). Conclusion: Our study found that TXA significantly reduced postoperative blood loss, painful postoperative swelling, and hematoma formation and subsequently reduced postoperative pain and opioid use following the Latarjet procedure. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
BACKGROUND:The purpose of this study was to investigate the blood supply of the humeral head (HH) originating from the anterior (ACHA) and posterior circumflex humeral arteries (PCHA).METHODS:Formalin preserved specimens were used to measure ACHA length, ACHA length in the bicipital groove (BG), the length of the ascending branch of the ACHA, the penetration point of the ascending branch of the ACHA at the greater tuberosity (GT), and the penetration point of the ascending branch PCHA at the GT. Fresh specimens were used to identify the intraosseous vascular network by both the ACHA and PCHA by injecting a contrast medium using a high-resolution microfocus computed tomography. Specimens were then dissected to expose where the branches of the ACHA and PCHA penetrate the bone, and a small section of the medial head was removed to visualize dye penetration of the cancellous bone.RESULTS:Seven variations for the course of the ACHA were observed. In 36%, the ACHA runs posterior to the BG and posterior to the long head of biceps tendon, and splits into the anterolateral ascending and descending branch. The ascending branch enters the medial wall of the GT. Microfocus computed tomography demonstrated that the intraosseous branch of the ascending branch of the ACHA runs within the GT in a medial direction from its penetration point just along the lateral edge of the BG. Intraosseous accumulation of contrast within the GT supply occurs more toward the inferior aspect of the HH, and the anterior-superior and superior-medial aspect of the HH is not perfused. This region is a high-risk zone for avascular necrosis.CONCLUSION:The results of this study suggest that 7 variations for the course of the ACHA exist. These variations and the interruption of the intraosseous arterial network in the GT with surgery and suture anchor placement result in a high-risk zone in the superomedial aspect of the humeral head overlapping with the area where early aseptic necrosis is identified.
Hypotheses: The analysis of well documented cases in the Germany Shoulder Arthroplasty Registry (SEPR) can (1) provide valuable detailed information (2) which are useful to improve patient care and guide treatment in the future. Revisions of shoulder replacement are the inevitable and elaborate consequence of primary implantation. Study design: retrospective registry study inclusion criteria: complete dataset in SEPR of primary revision shoulder arthroplasty from 1994-2018 exclusion criteria: multiple revisions, incomplete data statistical analysis using SPSS 25.0 The data set screening of n=8410 documented shoulder arthroplasties resulted in n=975 revision cases of which n=433 could be included. Data (mean, Min-Max; p): patient age anatomical arthroplasty (TSA) (n=254) 66.3 (28-89) vs. reverse arthroplasty (RSA) (n=179) 77.1 (45-89), p=0.001. No correlation of age and gender to survival. Frequent reasons for revision (TSA;RSA) (%): rotator cuff insufficiency (51.2; 28.5) p=0.001; dislocation (21.7;39.1) p=0.001; chronic infection (26; 32.4) p=0.146. Preop. imaging (%;p) (TSA;RSA): radiographs (76;70;0.259), CT (33;31;0.671), Arthro-CT (3;1;0.143), MRI (4;3;0.622), ultrasound (10;7;0.484), scintigraphy (2;2;0.911), biopsy (2;3;0.176). Frequent types of revision TSA (%): conversion to RSA (47), humerus (19), glenoid (41); RSA (%): other (27), humerus (20), glenoid (17). Frequent intraop. complications (TSA;RSA) (%): nothing (91;96) p=0.035; fracture of humeral shaft (3;2) p=0.462. Postop. complications TSA 31%, RSA 39%, p=0.372. Postop. complications TSA stemless none 78%, classic stem none 65%%, short stem none 64%, p=0.122. Survival (m) TSA 42.8 (0-240) vs. RSA 27.7 (0-361), p=0.001; arthroplasty for fracture anat. (FxA) 21.9 (0-182) vs. fracture reverse (FxR) 16.9 (0-46), p=0.795. Survival cemented stems TSA 37.7 (0-240) vs. uncemented TSA 27.7 (1-107), p=0.018; Survival cement. stems RSA 24.8 (0-193) vs. uncement. stems RSA 35.1 (0-361), p=0.715; cement. glenoid TSA 36.1 (0-240) vs. uncement. glenoid TSA 39.8 (0-182), p=0.527; uncement. RSA 27.7 (0-361). Survival TSA: classic stem 52.3 (0-240), short stem 27.9 (2-121), stemless 33.3 (0-144) (p=0.205); RSA: classic stem 24.0 (0-216), short stem 30.3 (0-361) (p=0.626). Intraop. complications in TSA stemless 2.3%, classic stem 9.7%, short stem 21.4% (p=0.018). Constant-Score at time of revision TSA vs. RSA 26.1 (0-65) ; 19.6 (0-49), p=0.001; ROM active Flex. 66 (0-160);57 (0-150), p=0.119; active Abd. 58 (0-160);53 (0-140), p=0,101; active ERO 18 (-30-70);9 (-19-40), p=0.003. No arthrodesis was performed at all. Results for TSA and RSA are significantly different for age at revision, survival, intraop. complications, reasons for revision and clinical function before revision (Constant score and active ERO).
Background: This study aimed to compare the functional and clinical outcomes between the deltoid split (DS) approach and the classic deltopectoral (DP) approach for locking plate fixation of proximal humerus fractures (PHF) in a prospective randomized multicenter study. Methods: From 2007 to 2015, all patients with a PHF Neer II/III were invited to participate. Exclusion criteria were pre-existing pathology to the limb, patient refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), and axillary nerve impairment. After consent, patients were randomized to one of the 2 treatments using the dark envelope method. Functional outcome was evaluated by validated questionnaires (12-Item Short Form Health Survey: version 2, Quick-DASH) with a minimum follow-up of 12 months. Complications were noted. Results: A total of 85 patients (44 DS, 41 DP) were randomized (mean age of 62). Groups were equivalent in terms of age, gender, body mass index, severity of fracture, and preinjury scores. The mean follow-up was 26 months. All clinical outcome measures were in favor of the deltopectoral approach. Specifically, the Q-DASH and SF-12v2 were better in the DP group (12 vs. 26, P=.003 and 56 vs. 51, P=.049, respectively). There were more complications in DS patients, but they did not reach statistical significance. Conclusions: The primary hypothesis on the superiority of the deltoid split incision was rebutted. On the basis of our study, the DP approach seems to offer better function compared with the DS approach for fixation of Neer 2 and 3 PHF fractures fixed with a locking plate. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
To report here the subjective and objective outcomes of a series of TSA, in patients younger than 60 years at the time of surgery, reviewed clinically and radiographically at a minimum of 2 years after surgery. Total shoulder arthroplasty (TSA) is currently preferred in young patients however, due to the limited survival of the glenoid component, the optimal treatment remains unclear for younger patients. We performed a retrospective multicenter study. Our inclusion criteria were all the stemmed-TSAs implanted in patients under the age of 60 with a minimum of 2 years of follow-up. Resurfacing and stemless arthroplasties as well as patients over 60 were excluded. Between 1993 and 2016, 460 primary TSAs were performed. Due to loss to follow-up, 65 patients had to be excluded leaving 395 shoulders in 332 patients for clinical and radiological analysis. The primary etiology of the arthritis was recorded. Clinical and radiological parameters were assessed before surgery, within 6 months after surgery, and then annually. Glenoid complications and cuff tears were the most frequently observed complications. 98 shoulders were revised, mainly for glenoid failure or infection, and 16 shoulders were re-operated, mainly for cuff tears or stiffness. At a mean follow up of 15 ypo, the survival-free revision was 63%. A statistical improvement of the range of motion, Constant score and satisfaction was observed at last follow-up. At last follow-up, 30% of patients presented a failure on the glenoid implant: either implant migration or loosening. Glenoid complications and revision are increasing with time. The clinical subjective and objective results were significantly better for patients without glenoid failure. The RLL score was significantly higher in patients with initial malposition. TSA is a reliable implant at mid-term follow up in younger patients with significant improvement in functional outcomes. However, there is a severe decline in glenoid implant survival over time, with the need to revise the implants.
Background: The purpose of this study is to evaluate which factors will affect range of motion (ROM) and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes. Materials and Methods: This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum 1-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio ulnar joint (PRUJ) implication. Outcomes included radiographic ROM measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS). Results: Mean follow up was 3.5 years (1-7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (-11 degrees, p = 0.004) and total ROM (-14 degrees, p = 0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (p = 0.001) and fractures involved the PRUJ in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated non-surgically or surgically. Discussion: We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries. (C) 2019 Published by Elsevier Masson SAS.
The vast majority of biceps injuries involve the long head of the biceps tendon. Less frequently, and typically in younger patients, the injury can occur through the muscle belly. Scattered case reports describe patients with a short head injury of the biceps alone.2DiChristina D.G. Lustig K.A. Rupture through the short head of the biceps muscle belly. A case report.Clin Orthop Relat Res. 1992; : 139-141PubMed Google Scholar Concomitant ruptures of both the short head of the biceps and coracobrachialis muscles are even rarer, as, to our knowledge, this has only been mentioned once in the literature.11Tobin W.J. Cohen L.J. Vandover J.T. Parachute injuries.J Am Med Assoc. 1941; 117: 1318-1321Crossref Scopus (25) Google Scholar In our case report, such an injury is presented, having occurred after a “skurfing” accident. Water skurfing is a recently popularized sport that is a form of water skiing. The participant rides a version of a surfboard, rather than skis, while being towed behind a motorboat.9Skurfing (sport) [Internet], Wikipedia.https://en.wikipedia.org/w/index.php?title=Skurfing_(sport)&oldid=864127361Date: 2018Google Scholar, 12Wakesurfing [Internet], Wikipedia.https://en.wikipedia.org/w/index.php?title=Wakesurfing&oldid=877228588Date: 2019Google Scholar This sport is similar to wakeboarding; however, in water skurfing, the participant's feet are not attached to the wakeboard, and the participant does not necessarily hold the rope at all times. Common wakeboarding injuries include head injuries, lacerations, anterior cruciate ligament tears, shoulder dislocations, fractures, and ankle sprains.1Carson Jr, W.G. Wakeboarding injuries.Am J Sports Med. 2004; 32: 164-173https://doi.org/10.1177/0363546503258910Crossref PubMed Scopus (31) Google Scholar, 5Hostetler S.G. Hostetler T.L. Smith G.A. Xiang H. Characteristics of water skiing-related and wakeboarding-related injuries treated in emergency departments in the United States, 2001-2003.Am J Sports Med. 2005; 33: 1065-1070https://doi.org/10.1177/0363546504271748Crossref PubMed Scopus (47) Google Scholar However, there are very limited reports detailing upper extremity injuries resulting from water skurfing.7Moorman C.T. Silver S.G. Potter H.G. Warren R.F. Proximal rupture of the biceps brachii with slingshot displacement into the forearm. A case report.J Bone Joint Surg Am. 1996; 78: 1749-1752Crossref PubMed Scopus (14) Google Scholar There may be potential for more severe injuries, as there is a greater risk of falls because the participant's feet are not fixed to the board. Furthermore, tricks are performed while obtaining slack in the rope, increasing the chance of entrapping an extremity and leading to injury through rope traction and compression. This mechanism of rope traction and compression itself is well described, especially in parachute jumpers and wake boarders; however, resultant ruptures of both the short head of the biceps and coracobrachialis muscles is rarely seen. Therefore, this case report aims to familiarize the reader with both this uncommon injury pattern and a successful treatment approach. A 15-year-old right-hand-dominant boy presented to the hospital with right arm pain and swelling hours after a traumatic fall while water skurfing. When he fell from the wakeboard, the rope wrapped around his right upper arm, resulting in a violent traction-type injury from the pull of the motorboat. He was an experienced skurfer without any prior injuries to his arm. Right elbow radiographs showed soft tissue swelling at the distal arm, but no fracture or dislocation, and the patient was discharged home. Because of continued swelling and pain, he returned to the hospital 2 days after the injury. Physical examination revealed swelling and ecchymosis of the anterior and medial surfaces of the arm. The extremity was neurovascularly intact. There were rope skin burns at the upper arm overlying a site of relative muscle mass defect. Distal to this region, just above the elbow, there was abnormal muscle contour (Fig. 1). Because of a concern for deep soft tissue injury, magnetic resonance imaging (MRI) of the right arm and elbow was performed. This demonstrated complete ruptures of the coracobrachialis and biceps short head muscle bellies at the level of the middle third of the arm, with distal retraction of both muscle bellies (Fig. 2). The imaging also showed that the biceps short head muscle belly had partially folded over itself and bulged into the medial aspect of the distal one-third of the arm. The exact locations at which the ruptures occurred were demonstrated to be within or near the muscle bellies themselves, because the tendon origins of both muscles were completely spared. Imaging also demonstrated severe tearing of the brachioradialis and extensor carpi radialis longus muscle bellies at the level of the elbow, including a 4.8×3.6×1.7-cm hematoma within this muscle (Fig. 2). The patient had no other associated injuries.Figure 2(a) MRI coronal image demonstrating transections of the short head biceps (long arrow) and coracobrachialis (short arrow) muscle bellies with proximal defect and distal retraction and folding over of the biceps; Cor FSEIR TR 4000/TE 36. (b) MRI axial image demonstrating defect (arrow) due to retraction of the short head biceps muscle belly; AX FSE T2FS TR 3000/TE 58. (c) MRI axial image demonstrating retracted biceps short head muscle bulging medially (long arrow) and partial tearing of brachioradialis muscle (short arrow); AX FSE T2FS TR 3000/TE 68. (d) MRI axial image demonstrating extensor carpi radialis longus muscle belly hematoma (*); AX FSE T2FS TR 3000/TE 68. MRI, magnetic resonance imaging; Cor, coronal; FSEIR, fast spin echo inversion recovery; TR, time to repetition; TE, time to echo; AX, axial; FSE, fast spin echo; T2FS, T2-weighted fat-saturated.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Given this constellation of injuries and the patient's continued pain, surgical reconstruction was contemplated and ultimately elected. Eight days after the injury, the patient was brought to the operating room. An anterolateral approach to the humerus was used. The radial nerve was lateral to the field and not visualized, and the brachial artery, median nerve, and ulnar nerve were medial and not identified. No muscle splitting was necessary. Surgical exploration confirmed that the biceps short head and coracobrachialis were torn across their muscle bellies, and that the distal stumps of both muscles were flipped distally (Fig. 3). The proximal stumps of the muscles were mobilized, reapproximated to the distal stumps, and secured with No. 2 FiberWire (Arthrex Inc, Naples, FL, USA) sutures. This was chosen to allow for continued strength while healing and to eliminate any worry about suture breakdown in the setting of delayed healing. A Krackow locking suture was used both proximally and distally. The forearm muscle injuries were left to heal conservatively. Postoperatively, the patient was splinted for comfort. The splint was removed on postoperative day 5, and at follow-up several days after surgery, the incision was healing appropriately (Fig. 4). At 3 weeks postoperation, the sling was used for comfort rather than full-time. At this time, a physical therapy protocol was started as well. The patient began with range of motion exercises, followed by lifting up to 2 lb as tolerated. This was increased to 5 lb at 6 weeks. By 10 weeks postoperation, he was limiting upper body conditioning to mild pain, and by 14 weeks, was able to return to full activities. At this point, he had excellent strength, full elbow range of motion, and a normal contour of the upper extremity. He was cleared to resume upper extremity conditioning and wrestling at that time.Figure 4At postoperative follow-up several days after surgery, the incision appeared to be healing well and the normal contour of upper arm musculature was restored.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In this case report, a traumatic injury from skurfing, a newly popular water sport, resulted in complete tears of the coracobrachialis and the short head of the biceps muscle in a 15-year-old boy. Specifically, his injury occurred when the rope was held in his armpit while he attempted a trick. When he fell, the rope wrapped around his arm, resulting in a forced traction injury. Although rope traction injuries have been described to cause biceps brachii tears, we were able to find only 1 report of both a complete coracobrachialis and short head of biceps brachii muscle rupture. This injury is mentioned in a 1941 article by Tobin et al,11Tobin W.J. Cohen L.J. Vandover J.T. Parachute injuries.J Am Med Assoc. 1941; 117: 1318-1321Crossref Scopus (25) Google Scholar in which a parachute jumper's arm and axilla were entangled in the static line that is connected to the plane for the automatic opening of the parachute, causing direct trauma. The article does not mention whether the patient was treated surgically to confirm the muscle tears, and no follow-up was reported. More recently, Heckman et al4Heckman J.D. Levine M.I. Traumatic closed transection of the biceps brachii in the military parachutist.J Bone Joint Surg Am. 1978; 60: 369-372Crossref PubMed Scopus (43) Google Scholar described a series of closed transections of the biceps brachii in military parachutists. More than 50 patients were encountered in a center performing in excess of 100,000 jumps per year. The injury occurred when the static line was medial to the arm as the paratrooper prepared to jump. The line created a localized force on the midportion of the arm. Acute injuries were treated with either surgical repair or immediate hematoma decompression and casting in full flexion for 6 weeks. Results showed similar healing in both groups and 77% of elbow flexion strength after correction for dominance. This report also included 6 patients treated at an average of 19 months after injury; in the surgically treated subset of these 6 patients, the muscle defect could not be corrected fully and only small improvements in strength were noted. This report suggests that early recognition and treatment of biceps brachii muscle ruptures leads to better functional outcomes. Similarly, a review article by Wilson et al13Wilson D.J. Parada S.A. Slevin J.M. Arrington E.D. Intrasubstance ruptures of the biceps brachii: diagnosis and management.Orthopedics. 2011; 34: 890-896https://doi.org/10.3928/01477477-20110922-25Crossref PubMed Google Scholar found that early surgical intervention with primary repair has been more successful than late reconstruction. Spiegl et al10Spiegl U.J. Faucett S.C. Millett P.J. Traumatic rupture of the coracobrachialis muscle: a case report.JBJS Case Connect. 2014; 4 (e54-e4)https://doi.org/10.2106/JBJS.CC.M.00294Crossref Scopus (4) Google Scholar published the only other report of a rupture of the coracobrachialis muscle from indirect, nonpenetrating trauma. The patient was lifting a heavy piece of equipment with his arm flexed at the elbow and shoulder when the machine jerked. He subsequently experienced diminished sensation over the lateral forearm and paresthesias when the elbow and shoulder were in flexion. MRI of the shoulder and elbow both failed to cover the area of injury, as the muscle defect was in the midportion of the arm. An upper extremity MRI scan diagnosed a distal rupture of the coracobrachialis at the musculotendinous junction. At the time of surgery 11 weeks after the injury, a neurolysis of the musculocutaneous and lateral antebrachial cutaneous nerves was performed. The muscle could not be anatomically repaired. To avoid compressing the surrounding neurovascular structures, the muscle was sewn to the adjacent biceps muscle. A similar injury report, by Moorman et al,7Moorman C.T. Silver S.G. Potter H.G. Warren R.F. Proximal rupture of the biceps brachii with slingshot displacement into the forearm. A case report.J Bone Joint Surg Am. 1996; 78: 1749-1752Crossref PubMed Scopus (14) Google Scholar involved a 15-year-old waterskiing on a boogie-board. This case involved a significant force translated to the arm resulting in a complete rupture of the biceps brachii with “slingshot displacement” of the muscle belly into the forearm. The force was so severe as to enable subcutaneous dissection to the muscle's resting place distally. At the time of surgery, the muscle was not viable and was excised, leaving the patient with approximately 30% loss of elbow flexion strength. This case offers another example of the high tensile loads that are an inherent hazard of waterskiing and related sports like skurfing. Pascual-Garrido et al8Pascual-Garrido C. Swanson B.L. Bannar S.M. Closed proximal muscle rupture of the biceps brachii in wakeboarders.Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1019-1021https://doi.org/10.1007/s00167-011-1654-2Crossref PubMed Scopus (9) Google Scholar detail 2 cases with a similar mechanism of injury from wakeboarding. Each patient had the rope handle caught around the arm as the boat was pulling at high speed. MRI in each case demonstrated complete tears of both heads of the biceps brachii muscle through the midportion of the muscle belly. In the first of these cases, the muscle was displaced into the forearm and was able to be repaired to the proximal myotendinous junction, eventually restoring full range of motion. In the second case, the biceps was necrotic and excised. In these cases, the mechanism was likely due to the boarder holding the rope handle in the crook of the elbow, from which it slid up to the shoulder then stripped the muscle from bone owing to the distal force on the rope from the boat. Finally, DiChristina and Lustig2DiChristina D.G. Lustig K.A. Rupture through the short head of the biceps muscle belly. A case report.Clin Orthop Relat Res. 1992; : 139-141PubMed Google Scholar reported a case in which a patient sustained an isolated short head of biceps rupture. This also occurred via a tow line as the patient fell while waterskiing. The fall occurred during a maneuver in which the patient had the tow line wrapped around his left arm to the level of the midforearm. The tendon was surgically repaired and the patient was placed in a shoulder immobilizer with elbow flexion greater than 90°, leading ultimately to an excellent result. Concurrent biceps short head and coracobrachialis injuries are so rare that there is no consensus on optimal management, although excellent results with early muscle repair have been reported.5Hostetler S.G. Hostetler T.L. Smith G.A. Xiang H. Characteristics of water skiing-related and wakeboarding-related injuries treated in emergency departments in the United States, 2001-2003.Am J Sports Med. 2005; 33: 1065-1070https://doi.org/10.1177/0363546504271748Crossref PubMed Scopus (47) Google Scholar, 6Kragh J.F. Basamania C.J. Surgical repair of acute traumatic closed transection of the biceps brachii.J Bone Joint Surg Am. 2002; 84: 992-998Crossref PubMed Scopus (46) Google Scholar Although our patient's skurfing injury itself is noteworthy, it is also important to note the utility of MRI in the diagnosis of these tears, because radiography is naturally limited in its ability to depict muscle pathology. Although clinical suspicion and physical examination have primary place in diagnosing severe traction injuries, the full extent of an injury may not be appreciated without advanced imaging. This is particularly relevant in a case such as ours, in which the combination of biceps short head and coracobrachialis tearing is so rare that many clinicians may suspect only the one injury and not the other if relying entirely on physical examination and history. Furthermore, complications such as hematoma and neurovascular compression can often be detected pre-emptively through MRI, as in our case, where there was a sizeable hematoma in the extensor carpi radialis longus muscle belly. MRI enables visualization of soft tissues with high resolution and excellent contrast, making it ideal for evaluating the severity of muscle injuries and identifying any associated injuries. This may assist both surgical planning and establishment of a postoperative recovery regimen.3Guermazi A. Roemer F.W. Robinson P. Tol J.L. Regatte R.R. Crema M.D. Imaging of muscle injuries in sports medicine: sports imaging series.Radiology. 2017; 281: 646-664https://doi.org/10.1148/radiol.2017160267Crossref Scopus (65) Google Scholar In our patient, correct diagnosis through imaging allowed for appropriate and timely surgical planning after an informed discussion regarding operative and nonoperative options. Prompt surgical reconstruction ultimately enabled the patient to have a successful outcome with no residual functional deficit. The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
BACKGROUND:Dislocation of total shoulder arthroplasty has an incidence as high as 31%. Obesity is one of many proposed risk factors, but no consensus exists on this relationship. The purpose of this study was to determine whether there is a relationship between body mass index (BMI) and dislocation of total shoulder arthroplasty.METHODS:The National Surgical Quality Improvement Program database was used to identify patients older than 50 years who underwent anatomic or reverse total shoulder arthroplasty between the years 2012 and 2016 for primary or secondary osteoarthritis, post-traumatic arthritis, or cuff tear arthropathy. Patients requiring reoperation or readmission for dislocation were identified by Current Procedural Terminology code. The relationship between World Health Organization BMI classification and dislocation was assessed.RESULTS:A total of 9382 patients were identified; 46% were male and 54% female, with an average age of 68.7 years (range 50-90) and average BMI of 31.2 (range 15.1-79.3). There were only 24 dislocation events within the first 30 days after the procedure (0.26%). Ten of 24 (42%) occurred after discharge. Seventy percent of cases (17 of 24) required an open procedure. Underweight patients (BMI < 18.5) experienced the highest dislocation rate (1/50, 2.00%), whereas overweight patients (BMI 25-29.9) experienced the lowest dislocation rate (3/3069, 0.1%).CONCLUSION:The rate of dislocation of total shoulder arthroplasty in the acute postoperative period differs across categories of BMI. However, there does not appear to be a linear association between BMI and risk of dislocation of total shoulder arthroplasty. Further studies are required to elucidate the risk factors for total shoulder dislocation.
The aim of the study was to prove mid-term results of reverse shoulder arthroplasty (RSA) regarding material design in a homogeneous monocentric collective in different etiologies (such as primary or secondary fractures or CTA). As hypothesis was defined that especially in fracture arthroplasties the prothesis design may increase functional outcome. Reverse shoulder arthroplasty (RSA) is meanwhile a common technique in complex shoulder situations. As established procedures obtain rotator cuff tear arthropathies (CTA), primary and secondary fractures. Cause of demographic changes, the incidence of proximal humeral fractures is increasing in past decades. Accordingly, primary and secondary fracture RSA implantation rates rose in the last years. Hundred-twenty (n=120) RSA patients with same material design between 2008 and 2016 were matched and included (ø 71 years, ø follow-up 59 months). The functional outcome was evaluated using age and gender related Constant Score (CSa), Quick DASH (QD) and Subjective Shoulder Value (SSV). Material Specifications, radiological outcomes, complications and adverse events were documented and statistically analyzed. Good to excellent mean results could be observed regarding etiologies (fracture vs. CTA): CSa: 70 (Ia + b) vs. 82 (2) {p = 0.021}, QD: 25 (Ia + b) vs. 15 (II) {p = 0.019}, SSV: 71% (Ia + b) vs. 81% (II) {p = 0.048}. Improved radiological and functional outcomes could be observed in primary fracture situations regarding material specifications in this RSA design. In RSA patients no significant benefit regarding material factor could be evaluated. Good mid-term functional results with a slightly range in clinical outcome and high patient satisfaction could be demonstrated in all groups, especially CTA patients protrude in superior functional results. In fracture circumstances certain material factors result in increasing clinical outcome.
Background: Total elbow arthroplasty (TEA) is a relatively infrequently performed procedure. Therefore, nationwide databases help to provide more insight into factors that might influence implant survival. for example. the surgical approach used. Using data from the Dutch Arthroplasty Register, we aimed to reveal whether high-volume centers use different approaches than low-volume centers and whether the approach is implant specific. Methods: Using data from 2014 to 2017, we compared the surgical approaches used for high- vs. low-volume centers, as well as for the 2 most frequently used types of TEA, by use of chi(2) tests. Results: We analyzed 276 procedures. In 2016 and 2017. when posterior approaches were further specified, the triceps-on approach was used most frequently in the high-volume center (27 of 42 procedures, 64%) and the triceps-flap approach was used most often in the low-volume centers (48 of 84 procedures, 57%) (P < .001). For the 2 most frequently used types of TEA, the Coonrad-Morrey and Latitude EV arthroplasties, the surgical approaches did not differ. When the high-volume center was compared with the low-volume centers, implant choice differed, with the Coonrad-Morrey arthroplasty being most often used in the high-volume center and the Latitude EV arthroplasty, in the low-volume centers. Conclusion: The posterior triceps-flap approach was the most frequently used surgical approach in primary TEA in the Netherlands, yet the triceps-on approach was used more often in the high-volume center. The surgical approaches did not differ between the 2 most frequently used types of TEA in the Netherlands. (C) 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
