Secure subscapularis repair is an essential element of total shoulder arthroplasty. Some surgeons prefer subscapularis peel because of ease of use, but some evidence suggests that lesser tuberosity osteotomy provides better fixation. The authors developed a novel, through-implant repair technique and performed a biomechanical study of its strength with cadaveric specimens. The authors obtained 20 matched pairs of cadaveric shoulders and inserted an uncemented short-stemmed humeral prosthesis that facilitates through-implant repair in all specimens. For each cadaver, the subscapularis was repaired with lesser tuberosity osteotomy and standard suture technique on 1 side, and the contralateral subscapularis was repaired with a novel through-implant suture repair and subscapularis peel technique. Displacement of the subscapularis footprint, ultimate load to failure, and stiffness of each repair were measured and compared between fixation groups. Mean±SD displacement of the lesser tuberosity osteotomy group was 0.75±0.94 mm at 10 cycles and 2.24±2.76 mm at 500 cycles. Mean±SD load to failure was 612±185 N, and mean±SD ultimate stiffness was 119±32 N/mm. No significant differences were noted between the lesser tuberosity osteotomy group and the subscapularis peel group in mean±SD displacement at 10 cycles (1.09±1.30 mm, P=.31), mean±SD displacement at 500 cycles (2.85±2.43 mm, P=.26), mean±SD load to failure (683±274 N, P=.31), or mean±SD ultimate stiffness (117±37 N/mm, P=.88). In a biomechanical testing model, through-implant subscapularis repair provided secure fixation relative to currently accepted subscapularis repair techniques in total shoulder replacement. [Orthopedics. 2016; 39(5):e937-e943.].

Reverse total shoulder arthroplasty (TSA) is a useful intervention for older patients with glenohumeral arthritis and a deficient rotator cuff. However, as a semiconstrained prosthesis, conventional reverse TSA implanted in a young patient could fail over time secondary to polyethylene wear and subsequent osteolysis. A metal-on-metal prosthesis may avoid this type of failure. The purpose of this study is to assess the outcomes in an initial cohort of young patients who underwent reverse TSA using a metal-on-metal prosthesis. Surgical indications included age younger than 50 years with a functioning deltoid and significant impairment of shoulder function with irreparable rotator cuff due to tumor resection, arthritis, or revision surgery. Nine patients with an average age of 37 years underwent implantation of a custom metal-on-metal reverse TSA prosthesis. All patients had a minimum 12-month follow-up or a failure of their procedure requiring revision surgery prior to 1 year. American Shoulder and Elbow Surgeons (ASES) scores, Constant scores, and range of motion were recorded and analyzed pre- and postoperatively to assess improvement, and all complications were noted. Average ASES score improved from 47 points preoperatively to 73.4 points postoperatively (P=.013). Average Constant and adjusted Constant scores improved from 20.8 points and 16% preoperatively to 61.8 points and 67.3% postoperatively, respectively (P=.019 and P=.068). Mean postoperative active forward flexion and active external rotation were 119.4° and 10°, respectively. Complications included the following: 3 patients sustained a postoperative dislocation, 1 patient had a glenoid fracture and complete loss of fixation of the baseplate, and 1 patient experienced dissociation of the glenosphere from the base-plate. Although metal-on-metal reverse TSA may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are disappointing, and the complication rate is high. [Orthopedics.2016; 39(5):e957-e961.].

Background: Anterior shoulder dislocation causes injury to the inferior gleno-humeral ligament (IGHL) and capsule. Clinical manoeuvres currently used to evaluate the IGHL test for, and may induce, apprehension. We developed the hyper extension-internal rotation (HERI) test to assess the IGHL and inferior capsule without causing apprehension or inducing a risk of gleno-humeral dislocation.Hypothesis: The HERI test is easy to perform and reproducible, induces no risk of gleno-humeral dislocation during the manoeuvre, and causes no apprehension in the patients.Material and methods: We studied 14 fresh cadaver shoulders. Each specimen was positioned supine with the lateral edge of the scapula on the table and the upper limb hanging down beside the table under the effect of gravity. This position produced hyperextension and internal rotation of the gleno-humeral joint. For each shoulder, the range of extension (degrees) was measured before and after isolated IGHL section. Then, we performed the HEIR test in 50 patients with chronic unilateral anterior gleno-humeral instability and we compared the range of extension between the normal and abnormal sides.Results: In the cadaver study, isolated IGHL section increased the angle of extension by a mean of 14.5 (11 degrees-18 degrees) compared to the pre-injury values. In the clinical study, the mean difference in extension angles between the normal and abnormal sides was 14.5 degrees. The patients reported no apprehension during the HERI test.Conclusion: The angle of extension increases after section or injury of the IGHL in cadaver specimens and patients, respectively. When the inferior capsule and IGHL are damaged, the angle of extension increases compared to the normal side. Lesions to these structures can be evaluated clinically by performing the HERI test. (C) 2015 Elsevier Masson SAS. All rights reserved.

Lors d’un accident d’instabilité antérieure gléno-humérale, le ligament gléno-huméral inférieur et la capsule inférieure sont lésés. L’ensemble des tests cliniques utilisés pour évaluer le ligament gléno-huméral inférieur recherchent et peuvent provoquer une appréhension. Nous décrivons un test en hyper-extension et rotation interne (HERI), témoin de l’état du LGHI et de la capsule inférieure, mais ne générant ni appréhension ni risque de luxation gléno-humérale.

Glenoid component loosening has been recognized as one of the common indications for revision surgery after total shoulder arthroplasty. Replacement with a standard glenoid component is sometimes possible when bone loss is minimal and contained within the glenoid vault. If glenoid bone stock is poor, more complex revision strategies include bone graft reconstruction, custom implants, and the use of augmented components. Reverse total shoulder arthroplasty has also developed into a platform for revision surgery. However, surgeons must be aware that when used for revision, complication rates are higher and survival times are shorter. Glenoid revision is technically demanding even for an experienced shoulder surgeon and may lead to early revision failures if done improperly. Shoulder surgeons must have a detailed understanding of expected outcomes, proper indications and current bone grafting techniques when attempting glenoid reconstruction.

Body: Objective: Clarify insulin resistance (IR), diabetes mellitus (DM) and low cerebral flow reserve contributions to stroke (S) and dementia (D). Methods: Among 300 patients with cerebral ischemia symptoms, brain SPECT indices of basal metabolism (CMi), stimulated perfusion (CPi) and cerebral flow reserve (FRi = CPi – CMi and FRr = net stimulated/basal counts) used parabolic renal corrections. Same day scans for FRi and FRr correlations had background < 30%. Test Your Memory (TYM) dementia cutoff was < 41/50. Results: In 34 near normal patients age (51.8+-14.6) years, CMi was (57.3+-4.4)%, FRi (10.0+-2.5)% and TYM 47.6+-1.5. For 43 patients with FRr calculations: (20FRi) = 45.83(1.4FRr)+0.87 with r = 0.93. In 128 IR cases, age (52.4+-14.2) years, FRi was -(0.24+-6.71)%, TYM (43.4+-3.6), S 14.1%, D 16.5%; similarly, in 172 DM cases, age (56.5+-12.3) years, FRi was -(0.16+-9.0)%, TYM (43.8+-5.6), S 11.6%, D 19.7%, Age of S+D patients was (56.4+-12.2) years for IR cases and (57.9+-11.7) years for DM cases. For IR patients, males were a similar 25.8% (33/128) of the total and 26.3% (5/19) of D cases; however, males comprised more, 47.7% (82/172) of total and 63.3% (19/30) of D cases among DM patients. Conclusions: Total S and D are similar in IR and DM, hence IR (prevalence > > DM) likely contributes predominantly to overall cognitive impairment. Cost effective blood tests for amyloid fragments (Pesini P, 2012) and focused brain uptakes (Pretorius, 2005) may further clarify if DM predisposes even more to dementia in men than periemenopausal women.

Large osteochondral defects of the glenohumeral joint are difficult to treat in young, active patients. Advanced surgical techniques have been developed that allow for biological resurfacing of the joint without using prosthetic implants, and such techniques offer potential benefits including faster rehabilitation, pain relief, and easier revision surgery if necessary. Early outcomes are encouraging in many cases, but inconsistent overall, with pain relief being the most reliable indicator of patient satisfaction.

The treatment of large, bipolar osteochondral lesions of the glenohumeral joint in young, active patients is challenging. When conservative treatment fails to provide acceptable results, restorative and reconstructive options are often considered. Despite its success in relieving pain and restoring function, total shoulder arthroplasty has significant drawbacks for young patients. One surgical option is an all-arthroscopic osteochondral total shoulder resurfacing using fresh osteochondral allografts. By using an arthroscopic approach, damage to surrounding structures, including the subscapularis, is minimized, resulting in decreased morbidity and rehabilitation required after surgery when compared to standard total shoulder arthroplasty.

Cognitive impairment includes neurodegenerative and cerebrovasular components which are seldom isolated and usually coexist. Neurodegeneration is primarily characterized by metabolic markers such as fluorodeoxy-glucose (FDG). We reported direct relation between cerebrovascular disease, including stroke, and a brain SPECT derived cerebral flow reserve index (FRi). Here we report that the product of a scaled, normalized cerebral metabolic index (CMi) and FRi, both from brain SPECT, quantitatively measures cognitive impairment. Tc-99m-HMPAO or Tc-99m-ECD were injected in quiet, dark rooms for basal (CMi) or post perfusion stimulants (e.g., 0.8 mg sl nitroglycerin or 500 mg IV acetazolamide) for the cerebral perfusion index (CPi) and FRi = CPi - CMi. Both CMi and FRi were normalized by subtracting them from their average peak value or range. Cognitive function was monitored by Test Your Memory (TYM). Interrelated risk groups for cognitive impairment included patients with traumatic brain injury (TBI), hypertension (BP >140/90), insulin resistance (IR), diabetes mellitus (DM), thyroid disease (Td), pituitary disease (Pd), high or low glomerular filtration rate (GFR in ml/min), monitored by deviation from GFR = 160 - A, where A is age in years and GFR estimated from serum creatinine or cystatin C. Near normal patients (n = 52), age (51.0+-14) years, similar to other patients, had FRi (9.7+-3.2), CMi (56.4+-9.9) and TYM (47.0+-1.8). Average DTYM = 50 - TYM correlated (r = 0.935; P = 0.001) with the normalized product NP = (0.1)(70-CMi)(20-FRi) so that DTYM = (0.20)(NP) + 0.17. For near normal patients, DTYM 3.0, NP 13.9; for 52 Pd, DTYM 9.8, NP 46.5; for 100 high GFR, DTYM 7.5, NP 35.2; for 173 DM, DTYM 5.9, NP 31.9; for 51 IR, DTYM 7.3, NP 31.2; for 125 hypertensives, DTYM 6.3, NP 35.5; for 91 TBI, DTYM 6.3, NP 32.3; and for 57 Td, DTYM 7.6, NP 32.7. FRi = 0 corresponded to 14% adult incidence of stroke and 83 patients with stroke or TIA had FRi = - 0.4 +- 8.8. The normalized product of FRi, the cerebral flow reserve index, and CMi, the cerebral metabolic index is a practical, quantitative measure of mild cognitive impairment and early dementia.

Purpose Radioscintigraphic imaging during sentinel lymph node (SLN) mapping could potentially improve localization; however, parallel-hole collimators have certain limitations. In this study, we explored the use of coded aperture (CA) collimators. Procedures Equations were derived for the six major dependent variables of CA collimators ( i.e. , masks) as a function of the ten major independent variables, and an optimized mask was fabricated. After validation, dual-modality CA and near-infrared (NIR) fluorescence SLN mapping were performed in pigs. Results Mask optimization required the judicious balance of competing dependent variables, resulting in sensitivity of 0.35%, XY resolution of 2.0 mm, and Z resolution of 4.2 mm at an 11.5-cm field of view. The findings in pigs suggested that NIR fluorescence imaging and CA radioscintigraphy could be complementary, but present difficult technical challenges. Conclusions This study lays the foundation for using CA collimation for SLN mapping, and also exposes several problems that require further investigation.

Objective: We evaluated the clinical and long-term functional outcomes of humeral diaphyseal fractures treated with acute anterior plating in a trauma population. Design: Single-center, retrospective cohort analysis with long-term prospective follow-up. Setting: Urban, Level I trauma center. Patients: Ninety-six patients with high-energy fractures of the humeral shaft were treated over a 10-year period. Intervention: All patients were treated by a standard surgical protocol of open reduction through an anterior approach with small or large fragment fixation in the supine position. Main Outcome Measurements: Mechanism of injury, time to union, complications, and range of motion during clinical follow-up were obtained. We also prospectively assessed long-term strength, range of motion, and perceptions of disability using the Disabilities of the Arm, Shoulder and Hand questionnaire. Results: Mean time to surgery was 5 days (standard deviation, 11 days); 97.5% of patients achieved union in an average of 16.9 weeks (range, 6–56 weeks). Complications included two postoperative infections, two nonunions, and three implant failures. Long-term follow-up (n = 34) averaged 4.75 years (range, 1.4–10.8 years). On average, no significant differences between the injured and uninjured extremities were seen in range of motion at the shoulder and elbow with the exception of shoulder flexion. A modest loss of upper extremity strength in the injured arm was appreciated. The mean Disabilities of the Arm, Shoulder and Hand score was 25.9 (range, 0–79). Conclusions: A standard anterior surgical approach with small fragment fixation is a safe and effective treatment for humeral shaft fractures in multiple trauma patients. We show a high union rate and few complications, although a modest loss of function and some perceived disability exists in the long-term.

Results: Mean time to surgery was 5 days (standard deviation, 11 days); 97.5% of patients achieved union in an average of 16.9 weeks (range, 6–56 weeks). Complications included two postoperative infections, two nonunions, and three implant failures. Long-term follow-up (n = 34) averaged 4.75 years (range, 1.4–10.8 years). On average, no significant differences between the injured and uninjured extremities were seen in range of motion at the shoulder and elbow with the exception of shoulder flexion. A modest loss of upper extremity strength in the injured arm was appreciated. The mean Disabilities of the Arm, Shoulder and Hand score was 25.9 (range, 0–79).

Mixed dementia (including Alzheimer's) risk may be increased by hypertension (BP), diabetes mellitus (DM), waist-height ratio (WH), traumatic brain injury (TI), thyroid (Td), renal (Rd), pituitary (Pd) disease and depression (De). To study dementia pathogenesis we developed a brain SPECT measure of cerebral flow reserve (CFi) with correction factors due to decreased tracer clearance in Rd. Outpatients age 22 to 93 years had mainly mild cognitive impairment by MMSE or Test Your Memory tests. Brain SPECT included basal, perfusion-stimulated (e.g. 500 mg acetazolamide IV) and post therapy (e.g. 1.2 mg liraglutide sq) with Tc-99m-HMPAO or Tc-99m-ECD. Cortical metabolic and perfusion indices (CMi, CPi) were calculated from basal and perfusion-stimulated SPECT. CFi = CPi - CMi was corrected by a flat 3% decrease, or from multicompartment analysis, for GFR < 60 ml/min (MDRD formula). De was defined by clinical exam. Hypertensive was untreated BP > 140/90, but treated before brain SPECT as was Td. Pd were treated if post hypophysectomy or post drug therapy. CFi = CPi - CMi was (5+-2)% for patients with low likelihood of disease, and CFi < 3%, the lower limit of normal. Ages were similar among the groups. CFi was low in 90% of Pd (47/52), 59% (80/135) of BP, 57% (43/75) of DM, 67% of De (35/52), 66% of Td (71/107) and 61% (56/92) of Rd, but only 30% in Rd (28/92) if CFi uncorrected. Most, 87% of Pd (55/63), had hypothalamic defects; 68% of Pd (43/63) had orbit frontal defects, of whom 42% or (18/43) had De. Stroke or TIA occurred in 31% of Pd (19/62), 30% of Rd (22/74) and 28% of DM (21/75). Most successful results were 68% of Pd (13/22) with normal CFi post-therapy. Particularly low CFi in Pd suggests a fundamental role of an intact neuroendocrine system to maintain CFi and prevent dementia. Moreover, effective endocrine therapy to improve CFi or prevent its age-related decline could be part of a more comprehensive set of specific therapies to decrease dementia risk. Clinical depression with such a multimodality approach will likely be significant and a key issue in quality of care.

Risk of mixed dementia (including Alzheimer's) is associated with hypertension (BP), diabetes mellitus (DM), waist-height ratio (WH), traumatic brain injury (TI), diseases of the thyroid (Td), renal (Rd) or pituitary (Pd) and depression (De). To study dementia pathogenesis we developed a brain SPECT measure of cerebral flow reserve (CFi) with correction factors due to decreased tracer clearance from the blood in Rd. Outpatients age 22 to 93 yrs had mainly mild cognitive impairment by MMSE or Test Your Memory tests. Brain SPECT included basal, perfusion-stimulated (e.g. 500 mg acetazolamide IV) and post therapy (e.g. 1.2 mg liraglutide sq) using Tc-99m-HMPAO or Tc-99m-ECD with calculated cortical metabolic and perfusion indices (CMi, CPi). For GFR < 60 ml/min (MDRD formula), CFi = CPi - CMi was corrected by a flat 3% decrease, or from multicompartment analysis. De was defined by clinical exam and hypertension by untreated BP > 140/90. Hypertension and Td were treated before brain SPECT. Pd were pre-or posttreatment (hypophysectomy or drug therapy). CFi = CPi - CMi was (5.2 + -3.9)% for 15 patients with low likelihood of disease. Ages were similar among all patient groups. CFi was < 3% in 90% of Pd (47/52), 59% (80/135) of BP, 57% (43/75) of DM, 67% of De (35/52), 66% of Td (71/107) and 61% (56/92) of Rd, but only 30% of Rd (28/92) with CFi uncorrected. Most, 87% of Pd (55/63) had hypothalamic defects; 68% of Pd (43/63) had orbitofrontal defects, of whom 42% or (18/43) had De. Stroke or TIA occurred in 31% of Pd (19/62), 30% of Rd (22/74) and 28% of DM (21/75). The most successful result was 68% of Pd (13/22) with normal CFi post-therapy. Low CFi particularly occurs in Pd, suggesting that an intact neuroendocrine system is fundamental to maintain CFi and prevent dementia. Pd and stroke are strongly associated with De, which is a key factor in patient quality of care. Effective endocrine therapy may improve CFi, or prevent its potential age-related decline, and is likely to be an important part of specific multimodality therapy to decrease risk of dementia.

Omega–3 unsaturated fats stimulate brain perfusion and may decrease Alzheimer's disease risk; low androgens increase Alzheimer's risk. We first used saturated fat to stimulate brain perfusion with the CRBU (Cortical Radioactive Brain Uptake) dementia screening method (Alzheimer's and Dementia 2005:1:S49–50). Describe omega–3 fat effect on brain perfusion and its diagnostic/therapeutic potential. The new CRBU method, COBRA (Correlative Brain Regional Activity) uses tungsten alloy collimation to further separate background, F–18 and Tc–99m signals. Brain metabolism studies used FDG–PET, FDG–SPECT or basal Tc–99m–HMPAO–SPECT. Brain perfusion studies also used Tc–99m–HMPAO–SPECT with 4 stimulants: 1) acetazolamide 0.5 g IV; 2) nitroglycerin, 0.6 mg sublingual; 3) saturated fat, 50 g oral; or 4) omega–3 fat, Omacor®, 10 g oral; the IV tracer given 10 min after the parenteral stimulants and 3 hrs after the oral ones. Cortical metabolic and perfusion indices (CMi, CPi) were defined by count ratios within 60% and 30% isocontours of regional peak brain activity. Manual region of interest analysis defined abnormal areas. COBRA had better energy (< 3% vs. > 10%) resolution than SPECT or PET and cost much less. Control patients (> 20) with nonspecific complaints had no more than one abnormal area of brain perfusion or metabolism; 60 study patients had 2 or more abnormal areas. Study outpatients complained of clinically verified memory loss and comprised three groups: A) neurodegenerative (CMi < CPi), B) vascular–autoimmune (CPi < CMi), and C) mixed. Comparison of the 4 stimulation methods revealed no significant difference in the number or overall prominence of abnormal perfusion areas. Each study group had significant differences from either CMi (60+–8%) or CPi (63+–9%) of the controls. After 1 to 4 g Omacor® oral daily for 1 to 3 months, 6 of 8 patients, including two with normal free testosterone but androgen resistance, had improved scans and /or symptoms. Both COBRA and SPECT allow efficient, cost effective studies of brain perfusion and metabolism. Further investigations should determine if Omacor® (or other) stimulation of brain perfusion, and possibly metabolism as well in the longer term, improves the clinical course of dementia.

Omega–3 unsaturated fats stimulate brain perfusion and may decrease Alzheimer's disease risk; low androgens increase Alzheimer's risk. We first used saturated fat to stimulate brain perfusion with the CRBU (Cortical Radioactive Brain Uptake) dementia screening method (Alzheimer's and Dementia 2005:1:S49–50). Describe omega–3 fat effect on brain perfusion and its diagnostic/therapeutic potential. The new CRBU method, COBRA (Correlative Brain Regional Activity) uses tungsten alloy collimation to further separate background, F–18 and Tc–99m signals. Brain metabolism studies used FDG–PET, FDG–SPECT or basal Tc–99m–HMPAO–SPECT. Brain perfusion studies also used Tc–99m–HMPAO–SPECT with 4 stimulants: 1) acetazolamide 0.5 g IV; 2) nitroglycerin, 0.6 mg sublingual; 3) saturated fat, 50 g oral; or 4) omega–3 fat, Omacor®, 10 g oral; the IV tracer given 10 min after the parenteral stimulants and 3 hrs after the oral ones. Cortical metabolic and perfusion indices (CMi, CPi) were defined by count ratios within 60% and 30% isocontours of regional peak brain activity. Manual region of interest analysis defined abnormal areas. COBRA had better energy (< 3% vs. > 10%) resolution than SPECT or PET and costs much less. Control patients (>20) with nonspecific complaints had no more than one abnormal area of brain perfusion or metabolism; 60 study patients had 2 or more abnormal areas. Study outpatients complained of clinically verified memory loss and comprised three groups: A) neurodegenerative (CMi < CPi), B) vascular–autoimmune (CPi < CMi), and C) mixed. Comparison of the 4 stimulation methods revealed no significant difference in the number or overall prominence of abnormal perfusion areas. Each study group had significant differences from either CMi (60+–8)% or CPi (63+–9)% of the controls. After 1 to 4 g Omacor® oral daily for 1 to 3 months, 6 of 8 patients, including two with normal free testosterone but androgen resistance, had improved scans and/or symptoms. Both COBRA and SPECT allow efficient, cost effective studies of brain perfusion and metabolism. Further investigations should determine if Omacor® (or other) stimulation of brain perfusion, and possibly metabolism as well in the longer term, improves the clinical course of dementia.