An analysis of the shoulder and elbow section of the orthopedic in-training examination

The Orthopaedic In-Training Examination (OITE) has been administered to orthopedic residents to assess knowledge and measure teaching quality. We performed a detailed analysis of the shoulder and elbow (S&E) section of the OITE relating to question content, recommended American Academy of Orthopaedic Surgeons references, and resident performance. S&E questions from the 2005-2009 examinations were analyzed for resident performance scores, tested topics, tested imaging modalities, tested treatment modalities, taxonomy classification, and recommended references. The S&E section made up 5.9% of the OITE. Mean resident performance on the entire OITE and on the S&E section improved during each training year. Imaging modality questions typically involved radiographs, magnetic resonance imaging, and computed tomography. These questions made up 37.5% of the S&E section. Treatment modality questions made up 45% of the S&E section and related mostly to shoulder arthroplasty and rehabilitation. Taxonomy classification showed that recall questions were most common. However, mean resident performance was minimally affected by question type. Recommended references were most commonly journal articles. Results of this study provided unique information related to content, recommended references, and resident performance on the S&E section of the OITE. We hope that use of this information will help improve resident performance and optimize S&E curricula.

Total shoulder arthroplasty utilizing mini-stem humeral components: technique and short-term results

INTRODUCTION

Throughout the field of orthopedic surgery, there has been a trend toward using smaller incisions and implants that preserve as much normal anatomy as possible. The use of bone sparing technology, such as partial and full surface replacements of the humeral head, while attractive in younger patients, does not allow the best exposure for proper glenoid replacement. Additionally, there are other situations when the use of surface replacements is contraindicated. There are also patients with an existing total elbow replacement or a humeral malunion or deformity in which a traditional long-stem component would not fit. For these reasons, a mini-stem humeral component for total shoulder arthroplasty was developed. In this study, we hypothesized that total shoulder replacement using the mini-stem humeral component could provide low complication rates and good to excellent results, as measured by postoperative Constant-Murley and UCLA shoulder scores at minimum 2 years postoperatively.

MATERIALS AND METHODS

This was a retrospective review of the first 49 mini-stem shoulder replacements (47 patients) for primary osteoarthritis. There were 26 male and 23 female patients. UCLA Shoulder Score and Constant Murley Scores were obtained on all patients at a minimum of 2 years postoperatively (average 29 months; range 24-43 months). Radiographs were interpreted by a musculoskeletal radiologist. Intraoperative blood loss was documented as was postoperative pain using a visual analog pain scale.

RESULTS

Patients experienced over 90% good to excellent results at minimum 2 year follow up. ROM improved significantly in all parameters. Postoperative UCLA scores at final follow up averaged 27.5 while Constant-Murley scores averaged 91. Small lucent lines (<1 mm) were noted in 11 patients. Five of 49 stems were placed in varus but the postoperative result was not affected in any of these patients. One patient suffered an acute subscapularis rupture that required repair.

CONCLUSIONS

This is the first report to document the efficacy of mini-stemmed humeral components used during total shoulder arthroplasty. Our study group showed good to excellent results as well as improvement in range of motion at minimum 2-year follow-up. The results presented in this study are comparable to previous outcomes achieved with conventional length humeral components, and suggest that mini-stem humeral components are an effective option for total shoulder arthroplasty.

Augmentation of a rotator cuff suture repair using rhPDGF-BB and a type I bovine collagen matrix in an ovine model

BACKGROUND

Rotator cuff tears are a common source of shoulder pain. High rates (20%-94%) of structural failure of the repair have been attributed to multiple factors, including poor repair tissue quality and tendon-to-bone integration. Biologic augmentation using growth factors has potential to promote tendon-to-bone integration, improving the function and long-term success of the repair. One such growth factor is platelet-derived growth factor-BB (PDGF-BB), which has been shown to improve healing in tendon and bone repair models.

HYPOTHESIS

Recombinant human PDGF-BB (rhPDGF-BB) combined with a highly porous type I bovine collagen matrix will improve the biomechanical function and morphologic appearance of the repair in a dose-dependent manner, relative to a suture-only control, after 12 weeks in an acute ovine model of rotator cuff repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

An interpositional graft consisting of rhPDGF-BB and a type I collagen matrix was implanted in an ovine model of rotator cuff repair. Biomechanical and histologic analyses were performed to determine the functional and anatomic characteristics of the repair after 12 weeks.

RESULTS

A significant increase in the ultimate load to failure was observed in repairs treated with 75 µg (1490.5 ± 224.5 N, P = .029) or 150 µg (1486.6 ± 229.0 N, P = .029) of rhPDGF-BB, relative to suture-only controls (910.4 ± 156.1 N) and the 500-µg rhPDGF-BB group (677.8 ± 105.9 N). The 75-µg and 150-µg rhPDGF-BB groups also exhibited increased tendon-to-bone interdigitation histologically. No differences in inflammation or cellularity were observed among treatments.

CONCLUSION

This study demonstrated that an interpositional graft consisting of rhPDGF-BB (75 or 150 µg) and a type I collagen matrix was able to improve the biomechanical strength and anatomic appearance in an ovine model of rotator cuff repair compared to a suture-only control and the 500-µg rhPDGF-BB group.

CLINICAL RELEVANCE

Recombinant human PDGF-BB combined with a type I collagen matrix has potential to be used to augment surgical repair of rotator cuff tears, thereby improving clinical success.

Arthroplasty for fractures of the proximal part of the humerus

Proximal humeral fractures account for 4% to 5% of all fractures. Most of these fractures are nondisplaced or minimally displaced and amenable to nonsurgical treatment or open reduction and internal fixation. Complex proximal humeral fractures with displaced three- and four-part fragments, fracture-dislocations, and humeral head splits are more difficult to treat. In older patients, hemiarthroplasty or reverse shoulder arthroplasty is often the indicated treatment. Arthroplasty in this patient cohort is very technique-dependent and relies on preserving deltoid function, proper component placement and fixation, and tuberosity healing. Complications include tuberosity nonunion, instability, heterotopic ossification, and infection. Although pain relief is predictable, it is often difficult to achieve functional improvement. Results depend on the patient's age, timing of the surgery, tuberosity healing, and adequate rehabilitation. Recently, successful outcomes for reverse total shoulder arthroplasty have been reported in older, low-demand patients with cuff deficiency, deficient bone in the tuberosity, or compromised healing of the tuberosity.

Use of the 70° arthroscope for improved visualization with common arthroscopic procedures

The vast majority of common arthroscopic procedures are performed with a 30° arthroscope for visualization. Although the 70° arthroscope has been described for a myriad of applications, its utility has recently been forgotten. We have explored the use of the 70° arthroscope for a myriad of arthroscopic procedures and identified a number of circumstances in which it offers superior visualization to a 30° arthroscope. These procedures include arthroscopic shoulder stabilization, distal clavicle resection, acromioclavicular joint reconstruction, rotator cuff repair, elbow arthroscopy, anterior cruciate ligament reconstruction, posterior cruciate ligament reconstruction, arthroscopy of the posterior knee compartments, hip arthroscopy, and subdeltoid shoulder arthroscopy.

Histologic stages of healing correlate with restoration of tensile strength in a model of experimental tendon repair

Much current research is focused on biologic enhancement of the tendon repair process. To evaluate the different methods, which include a variety of gene therapy and tissue engineering techniques, histological and biomechanical testing is often employed. Both modalities offer information on the progress and quality of repair; however, they have been historically considered as two separate entities. Histological evaluation is a less costly undertaking; however, there is no validated scoring scale to compare the results of different studies or even the results within a given study. Biomechanical testing can provide validated outcome measures; however, it is associated with increased cost and is more labor intensive. We hypothesized that a properly developed, objective histological scoring system would provide a validated outcome measure to compare histological results and correlate with biomechanics. In an Achilles tendon model, we have developed a histological scoring scale to assess tendon repair. The system grades collagen orientation, angiogenesis, and cartilage induction. In this study, histology scores were plotted against biomechanical testing results of healing tendons which indicated that a strong linear correlation exists between the histological properties of repaired tendons and their biomechanical characteristics. Concordantly, this study provides a pragmatic and financially feasible means of evaluating repair while accounting for both the histology and biomechanical properties observed in surgically repaired, healing tendon.

Massive tears of the rotator cuff

Repair of massive rotator cuff tears is technically difficult but often feasible. Technical and biological challenges to a successful repair include inelastic poor-quality tendon tissue, scarring, muscle atrophy, and fatty infiltration. Fatty infiltration of the involved rotator cuff muscles has been identified as an important negative prognostic factor for the outcome after repair of massive rotator cuff tears. Tendon transfer is a good option for young patients and manual laborers with an irreparable massive rotator cuff tear. Arthroplasty can be considered for the treatment of symptomatic massive rotator cuff tears in patients who have glenohumeral arthritis.

Elbow medial ulnar collateral ligament reconstruction: clinical relevance and the docking technique

INTRODUCTION

Elbow ulnar collateral ligament (UCL) reconstruction has become the standard of care for the throwing athlete with a symptomatic ruptured or insufficient ligament and the desire to resume competitive play. Since Jobe's initial description of UCL reconstruction, the technique has evolved. A novel modification was the "docking" technique developed by Altchek. Subsequently, the docking technique as originally described was slightly modified. Arthroscopy is no longer routinely performed, and in some cases, a 3-strand graft is used.

MATERIALS AND METHODS

We treated 21 overhand athletes with clinical and radiographic evidence of UCL insufficiency with ligament reconstruction using a modified version of the docking technique using a 3-strand graft. There were 5 professional, 11 college, and 5 high school baseball players in the reconstructed group. Athletes were evaluated postoperatively by use of the Conway Scale.

RESULTS

Of the 21 patients who underwent the modified docking technique with a three-strand graft, 19 (90%) had excellent results. There were 2 good results and no complications.

DISCUSSION

UCL reconstruction can successfully treat athletes with UCL insufficiency. Several different reconstruction techniques have been described. By use of the docking and modified docking techniques, good to excellent results can be achieved in the majority of cases with a low complication rate.

Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge

HYPOTHESIS

This study reviewed a series of patients diagnosed with Propionibacterium acnes infection after shoulder arthroplasty in order to describe its clinical presentation, the means of diagnosis, and provide options for treatment.

MATERIALS AND METHODS

From 2002 to 2006, 11 patients diagnosed with P acnes infection after shoulder arthroplasty were retrospectively reviewed and analyzed for (1) clinical diagnosis; (2) laboratory data, including white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); (3) fever; (4) number of days for laboratory growth of P acnes; (5) organism sensitivities; (6) antibiotic regimen and length of treatment; and (7) surgical management. Infection was diagnosed by 2 positive cultures.

RESULTS

Five patients had an initial diagnosis of infection and underwent implant removal, placement of an antibiotic spacer, and staged reimplantation after a course of intravenous antibiotics. In the remaining 6 patients, surgical treatment varied according to the clinical diagnosis. When infection was recognized by intraoperative cultures, antibiotics were initiated. The average initial ESR and CRP values were 33 mm/h and 2 mg/dL, respectively. The average number of days from collection to a positive culture was 9. All cultures were sensitive to penicillin and clindamycin and universally resistant to metronidazole.

DISCUSSION

Prosthetic joint infection secondary to P acnes is relatively rare; yet, when present, is an important cause of clinical implant failure. Successful treatment is hampered because clinical findings may be subtle, many of the traditional signs of infection are not present, and cultures may not be positive for as long as 2 weeks.

Symptomatic glenoid loosening complicating total shoulder arthroplasty

Glenoid component loosening is one of the most common causes of failed total shoulder arthroplasty. Previous reports indicate that it is desirable to reimplant the glenoid component during revision shoulder arthroplasty. The purpose of our study was to retrospectively evaluate the satisfaction of patients undergoing glenoid revision (reimplantation or resection) following total shoulder replacement specifically for symptomatic glenoid loosening. Twenty-eight shoulders that developed symptomatic glenoid loosening following primary total shoulder arthroplasty were included in the study. Patients were retrospectively evaluated at a minimum of 2 years postoperatively. Patients either underwent resection followed by reimplantation of the glenoid component (13) or resection of the component with or without bone grafting (15). Each patient was evaluated with the UCLA Shoulder Scale and the Constant-Murley Shoulder Assessment. There were seven excellent, 13 good, five fair and three poor results on the UCLA score. Functional outcome scores trended higher in the reimplantation group but were not statistically significant. Both groups reported equal pain relief and satisfaction. Five out of 15 patients underwent arthroscopic resection of the glenoid, and these patients scored as well on the UCLA and Constant scores as the reimplantation group. When symptomatic glenoid loosening is the indication for revision total shoulder replacement, patients tend to achieve good to excellent results. Though functional scores were slightly higher in the reimplantation group, satisfaction was equally high in both groups. Resection, when indicated, should be performed arthroscopically as this improved functional outcome in our series.

Hemiarthroplasty and total shoulder arthroplasty for avascular necrosis of the humeral head

The purpose of this study was to review the outcome of patients with osteonecrosis of the humeral head, based on etiology and treatment with either hemiarthroplasty or total shoulder arthroplasty (TSA). Sixty-four shoulders, with an average age of 57 years, were evaluated at a mean of 4.8 years. Outcomes included L'Insalata and American Shoulder and Elbow Surgeons (ASES) scores, as well as range of motion (ROM). The overall ASES score was 67, average flexion was 127 degrees, and external rotation was 49 degrees. Outcomes did not differ based on etiology, but ROM was decreased with post-traumatic osteonecrosis. There was no difference in outcome or ROM between hemiarthroplasty and TSA. The complication rate was significantly higher with TSA (22%) than with hemiarthroplasty (8%). Achieving ROM in patients with post-traumatic osteonecrosis remains difficult. TSA was associated with a higher complication rate and decreased mobility and should be reserved for patients with stage V osteonecrosis.

The DMD knot: a new locking, flip knot

To perform an arthroscopic rotator cuff or labral tear, surgeons need to know how to tie athroscopic knots. The ideal knot should be able to withstand large biomechanical loads while being easy to tie. With numerous knot configuration options available to surgeons, many recent studies have assessed the biomechanical characteristics of some of the more commonly used knots. Different studies have referred to the flip knot used by the senior author (DMD) as the "Dines knot," and in many of these studies, it has exhibited the best loop security, resistance to sliding, distance to failure, knot security, knot weight, and resistance to reverse slippage. To date, there is no published technique note on how to tie the Dines knot, which is referred to in this note as the "DMD knot."

Tissue engineering and rotator cuff tendon healing

Rotator cuff tears are common soft-tissue injuries that often require surgical treatment. Initial efforts to better tendon healing centered on improving the strength of the repair. More recent studies have focused on biologic enhancement of the healing process. Tissue engineering is a multidisciplinary field that involves the application of scientific principles toward creating living tissue to replace, repair, or augment diseased tissue. Gene therapy involves the transfer of a certain gene into a cell so that the cell translates the gene into a specific protein. The advantage of using a gene-therapy, tissue-engineered approach to effect healing rests in the ability of the physician to select growth factors with documented roles in the tendon-healing cascade. Ideally, an improvement to the current repair technique would yield improved tendon healing leading to improved clinical results.

Effect of total shoulder replacements on airport security screening in the post-9/11 era

There are few reports in the literature on the effect of orthopaedic implants on airport security devices and none on shoulder arthroplasty implants after September 11, 2001. Since 9/11, airport security screening devices have become more sensitive in response to the increasing threat of terrorism. Often, patients with joint implants activate the metal detectors and are subsequently subjected to more intensive screening. We assess the effects of shoulder joint implants on different airport security devices and what effect the results had on passenger travel. In this study, 154 patients who had previously undergone shoulder replacement responded to a questionnaire regarding their travel experiences after 9/11. Of these, 85 had flown during the time period studied (47 men and 38 women; mean age, 67.8 years); 79 had traveled domestically (mean, 7 flights), and 22 had taken international flights (mean, 6.1 flights). The questionnaire addressed each patient's height/weight, the number of flight segments flown (domestic and international), the number of times that a patient activated the doorway alarm/wand alarm, and the effect of a card stating that the patient had joint replacement (when applicable). On average, patients with shoulder replacement traveling domestically activated the security gate 52% of the time. The average for international travel was 42%. Of the patients who flew both domestically and internationally, there was a high correlation of activation (R = 0.54). Twenty-six patients had multiple joint implants (mean, 2.8). Multiple joint implants caused increased alarm activation (P < .001). All patients reported that their travel was delayed during the instances of security activation. There was no statistically significant effect of body mass index, height, weight, age, or sex on security device activation. Of the patients, 71% were told by their doctor that the shoulder replacement may activate security devices. Of these, 46 were given a card by their doctor indicating the presence of a total joint implant. In only 30% of the security encounters of these patients did the card expedite the screening process. This is the largest study on the effects of joint implants, and shoulder implants in particular, on airport security devices and the only one that has analyzed the data of post-9/11 travel. Patients traveling after total shoulder replacement are often delayed and subjected to more rigorous screening when traveling, especially in the post-9/11 environment. Doctors often warn their patients of potential problems and may try to avert this by giving them cards documenting the presence of a joint implant. The acceptance of these cards is sporadic. This study raises the importance of notifying patients of potential security delays, especially those with multiple joint implants, as they may directly affect travel plans. In addition, these patients may benefit from the establishment of an international joint registry.

The effect of growth differentiation factor-5-coated sutures on tendon repair in a rat model

Tendon ruptures are common injuries that are often treated surgically. Growth Differentiation Factor-5 (GDF-5) has been shown to accelerate tendon healing with varying degrees of success. We used a novel technique to apply recombinant human GDF-5 (rhGDF-5) to suture and hypothesized that controlled, local delivery of rhGDF-5 can be used to enhance tendon repair. Tendons of 92 rats were transected and repaired with sutures. All researchers were blinded to the following treatment groups (24 rats in each group): 0 rhGDF (control), 24 ng/cm rhGDF, 55 ng/cm rhGDF, and 556 ng/cm rhGDF. Rats were euthanized at 3 weeks (n = 48) and at 6 weeks (n = 48). Sutures were coated with rhGDF-5 using a novel dip-coat technique. Enzyme-linked immunosorbent assay confirmed consistent and reproducible delivery of rhGDF-5. Within each group, 8 were tested biomechanically, and 4 were assessed histologically. Histologic grading at 3 weeks showed improved healing in tendons repaired with coated suture versus controls. By 6 weeks, there were no significant differences. At 3 weeks, minimal isolated cartilage formation was observed; 6-week samples showed more extensive presence, typically surrounding suture fibers. At 3 weeks, tendons repaired with rhGDF-5-coated sutures resulted in significantly higher ultimate tensile load and stiffness compared with control sutures (P < .05) At 6 weeks, there were no significant differences in the mechanical properties of repaired tendons. At 3 weeks, rhGDF-5 induced significant tendon hypertrophy that was more pronounced than at 6 weeks. In addition, tendons repaired with rhGDF-5 showed an increased rate of healing versus control repairs at 3 weeks. This study showed that a novel dip-coating technique can be used to deliver growth factors in varying concentrations to local repair sites to accelerate tendon healing.

Irreparable rotator cuff tears: what to do and when to do it; the surgeon's dilemma

Irreparable rotator cuff tears have been defined as those tears that because of their size and retraction cannot be repaired primarily. Patients with an irreparable tear present with a variety of symptoms and physical findings, and their management depends on the clinical situation and the specific location of the tear. Most of these tears occur in the older, less active patient and many of these patients are best treated without surgery. For those in whom surgery is indicated, the best procedure should be tailored to the tear.

Imaging of the painful shoulder in throwing athletes

A wide spectrum of abnormalities can affect the throwing shoulder. The injuries are often particular to a specific phase of the throw and are well demonstrated with MR imaging. In this article, the authors review the phases of the throw, MR imaging techniques, and the MR appearances of the injuries associated with particular phases.

Outcomes analysis of revision total shoulder replacement

BACKGROUND

The number of total shoulder arthroplasties has increased exponentially over the last ten years, creating a more prominent role for revision shoulder arthroplasty in the future. The main reasons for failure of shoulder arthroplasty can be classified as soft-tissue deficiencies, osseous deficiencies, component wear, or infection. We hypothesized that, despite appropriate surgical techniques, the outcome of revision total shoulder replacement can be predicted on the basis of the indication for the revision procedure.

METHODS

We conducted a retrospective review of seventy-eight shoulders that had undergone revision shoulder arthroplasty. The shoulders were divided into two categories: (1) those with osseous or component-related problems and (2) those with soft-tissue deficiency. Category 1 consisted of four cohorts of shoulders: twenty-two treated with revision of the glenoid component, sixteen treated with conversion of a hemiarthroplasty to a total shoulder arthroplasty because of glenoid arthrosis, eight treated with revision of the humeral stem, and four treated for a periprosthetic fracture. Category 2 consisted of five cohorts of shoulders: ten treated with rotator cuff repair following total shoulder replacement, four with a failed tuberosity reconstruction, four with cuff tear arthropathy, five with instability, and five with infection. Patients were evaluated with the UCLA subjective outcome instrument, the L'Insalata shoulder questionnaire, and a subjective satisfaction scale (maximum score of 5 points).

RESULTS

The average UCLA score was 21.4 points and the average L'Insalata score was 68.73 points for the seventy-eight shoulders that were analyzed. The average score on the subjective satisfaction questionnaire was 2.91 points. According to the UCLA scores, twenty-four revisions were considered to have had an excellent result; fifteen, a good result; twenty-four, a fair result; and fifteen, a poor result. The average scores for the category-1 shoulders were significantly better than those for the category-2 shoulders (p < 0.05). Of the different types of operations, revision or implantation of a glenoid component and open reduction and internal fixation of a periprosthetic fracture provided the best outcomes. Tuberosity reconstruction, hemiarthroplasty for treatment of cuff tear arthropathy, and revision due to infection had uniformly poor outcomes.

CONCLUSIONS

In general, these results indicate that the outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure. Component revisions, excluding humeral head revision for salvage, provide the best results, whereas soft-tissue reconstructions can be expected to yield poorer results overall.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Long head of the biceps pathology as a cause of anterior shoulder pain after shoulder arthroplasty

The use of shoulder arthroplasty has been increasing over the last decade, with nearly 20,000 shoulder arthroplasties being performed each year. Although many patients have excellent results, there exists a subset of patients in whom anterior catching shoulder pain develops after arthroplasty. The purpose of this study was to examine this group of patients and explore treatment options and outcomes for this condition. We undertook a review of 8 shoulders in 7 patients who were treated for anterior shoulder pain radiating into the biceps muscle after shoulder arthroplasty. Three patients had a hemiarthroplasty for fracture, and five had a total shoulder arthroplasty. All patients had anterior shoulder pain with physical examination findings consistent with biceps tendon pathology. Definitive diagnosis and treatment consisted of either arthroscopy, in 7 of 8 shoulders, or an open procedure, in 1 of 8 shoulders. The range of motion improved in all shoulders. The hemiarthroplasty group showed an increase in flexion of 36 degrees (range, 68 degrees -104 degrees ), external rotation of 23 degrees (range, 11 degrees -34 degrees ), and internal rotation to L4. The total shoulder group demonstrated an increase in flexion of 50 degrees (range, 66 degrees -166 degrees ), external rotation of 27 degrees (range, 22 degrees -39 degrees ), and internal rotation to L3. The Hospital for Special Surgery score improved in all shoulders, with all patients being satisfied with their final outcome. Pain scores improved from a mean of 6.9 (range, 4-9) preoperatively to 1.4 (range, 0.5-2) postoperatively on a scale of 1 to 10, with 10 indicating the most pain. The role of the biceps tendon in the pathology of anterior shoulder pain after shoulder arthroplasty appears to be consistent with fibrosis and inflammation. Initial results, achieved with arthroscopic debridement or tenodesis, were encouraging.

Diagnosis and management of massive rotator cuff tears: the surgeon's dilemma

Several studies have documented high success rates following the surgical treatment of full-thickness rotator cuff tears. Historically, however, less favorable and predictable results have been found in the treatment of massive tears (>5 cm) compared with small and medium sized tears. Determining the most appropriate treatment for a patient with a massive rotator cuff tear can be challenging because of inconsistent outcome results. Some patients function well with nonsurgical treatment of massive tears, some have initially favorable results from surgical débridement of tears without repair that then deteriorate over time, and other patients who are surgically treated continue to maintain good function despite documented retears. Nonsurgical treatment of massive rotator cuff tears may be suitable for elderly patients with chronic tears and limited functional goals below shoulder level. Surgical débridement without repair of the tear may be considered for patients with low physical demands whose predominant symptom is pain. Surgical repair is recommended for patients who require maximal postoperative function, particularly for overhead activities. Open repairs have a lower rate of rerupture than arthroscopic repairs; however, arthroscopic repair offers the benefits of decreased morbidity and decreased risk of postoperative deltoid detachment. Early studies of arthroscopic repairs have shown good functional results; however, there has been a high incidence of retears. Tendon transfers and other reconstruction techniques may offer improvements in certain salvage cases, but results of these procedures are inferior to those for primary repair. Preservation of the coracoacromial arch should be considered in all forms of treatment of massive rotator cuff tears to avoid the devastating complication of superior humeral head escape.

Diversification of the Ig variable region gene repertoire of synovial B lymphocytes by nucleotide insertion and deletion

Although the changes that occur in Ig V region genes during a B lymphocyte's response to antigen usually result from point mutations, nucleotide insertion and deletion also alter gene sequence. We identified nucleotide insertions and deletions (3 to 12 bp) at a frequency of 1.34%, in Ig V gene cDNA from B lymphocytes residing in the synovial tissues of patients with rheumatoid arthritis. Because the added or lost nucleotides occurred in multiples of 3, they maintained the original reading frame and coded a potentially intact receptor. These V gene modifications were generated somatically, because they were identified in the original cDNA by HCDR3-specific polymerase chain reaction and were not found in other B cells using the same VH genes. Insertions and deletions were detected only in IgG+ and IgA+ transcripts, which exhibited 3 times more point mutations than IgM+ transcripts. In addition, they were usually found in the complementarity determining region, typical targets of somatic mutation. The occurrence of insertion/ deletion in isotype-switched cDNA with higher numbers of V gene mutations that localized to hot spots for V gene mutation suggests that these diversification events were related to the somatic hypermutation process. In support of this, an AGY hot spot motif and a short stretch of DNA similar in sequence to the inserted or deleted segments could be found next to the insertions/deletions, suggesting that these modifications arose from DNA duplication following DNA stand breaks. Thus, nucleotide insertion/deletion can lead to B-cell receptor diversification in B lymphocytes that clonally expand in synovial tissues of patients with rheumatoid arthritis.

Arthroscopic assisted rotator cuff repair

The advent of the arthroscope has revolutionized orthopaedic surgery, particularly for injuries to the knee or shoulder. The enhanced visualization accompanied by minimal soft tissue injury afforded by the arthroscope has been applied successfully to the treatment of many shoulder girdie pathologies, most notably impingement syndrome and rotator cuff injuries. As such, the traditional open surgery with the incumbent morbidity, while still utilized for more complex tears is finding less application in smaller tears to the rotator cuff. This review will address the history, indications, technique, and results of arthroscopic rotator cuff repair.

Coracoid impingement syndrome, rotator interval reconstruction, and biceps tenodesis in the overhead athlete

Anterior shoulder problems are extremely common in throwing athletes. Coracoid impingement syndrome, lesions of the long head of the biceps tendon, and rotator interval lesions are included in the extensive differential diagnosis which exists for anterior shoulder pain. In this article, we focus on the anatomy, pathophysiology, clinical presentation, diagnosis, and surgical treatment of these conditions.

Arthroscopy for failed shoulder arthroplasty

PURPOSE

It was the purpose of this study to describe the specifics of technique and results of arthroscopic evaluation and treatment of failed shoulder arthroplasties in 10 patients with early and late complications of shoulder arthroplasty.

TYPE OF STUDY

Case series.

MATERIALS AND METHODS

Ten patients (2 bilateral) underwent 13 arthroscopies after poor results following shoulder arthroplasty. The arthroscopic diagnoses ranged from rotator cuff tears in 5 shoulders, fibrosis and scarring of the long head of the biceps in 5 shoulders, impingement and biceps tendinitis in 1 shoulder, and capsular contracture in 1 shoulder. We performed 4 mini-open rotator cuff repairs, 1 open rotator cuff repair with revision of the humeral component, 5 arthroscopic debridements of the long head of the biceps, 2 arthroscopic decompressions with biceps tenodesis, and 1 arthroscopic capsular release.

RESULTS

Before arthroscopy, the preoperative Hospital for Special Surgery (HSS) scores were 6 fair and 6 poor. At latest follow-up, there were 3 excellent, 4 good, and 5 fair results. There was a statistically significant improvement in HSS scores and range of motion for all patients in this study. All patients were satisfied with the results of the procedure. There were no infections or wound problems and neurovascular status was unaltered after arthroscopy. There was 1 intraoperative complication, a periprosthetic humerus fracture after manipulation in an osteoporotic woman with rheumatoid arthritis.

CONCLUSION

Arthroscopy proved to be a reliable diagnostic and therapeutic tool in dealing with some of the postoperative complications encountered both early and late after shoulder arthroplasty. Careful attention to surgical technique, including use of blunt trocars, traction, and intraoperative prophylactic antibiotics, can minimize complications of arthroscopy in this setting.

Proximal humerus malunions

Malunion of a proximal humerus fracture often is painful and debilitating. Operative management of this deformity is technically demanding and frequently results in a relatively high rate of complications. Reconstruction involves a spectrum of procedures including excision of bony prominences, tuberosity osteotomy and realignment, and shoulder arthroplasty. This article covers the etiology, classification, diagnosis, and management of these complex injuries. A successfully performed reconstruction diminishes the patient's pain and potentially increases function.

Glenoid replacement in total shoulder arthroplasty

The outcome of total shoulder arthroplasty is largely based on the quality of glenoid component fixation, which, in turn, is related to the amount and quality of bone stock, glenohumeral stability, and rotator cuff function. This article discusses the anatomic and pathologic indications for glenoid replacement, surgical techniques, and results.

Familial calcification of the superior transverse scapular ligament causing neuropathy

Two patients, members of the same family, were found to have entrapment of the suprascapular nerve from a calcified superior transverse scapular ligament. The chief complaint in both cases was pain and weakness and atrophy of the supraspinatus and infraspinatus muscles. The nerve entrapment was confirmed by electromyographic studies and required surgical decompression to relieve the symptoms in both patients. Release of the entrapped nerve resulted in complete pain relief and full return of strength at 1-year followup.

Hemiarthroplasty of the shoulder for rotator cuff arthropathy

Sixteen patients underwent hemiarthroplasty for rotator cuff arthropathy between June 1989 and March 1992, and evaluations obtained before and after surgery in all patients were compared. A modular head large enough to articulate with the coracoacromial arch but not so large as to prevent approximately 50% of humeral head translation on the glenoid was used in these cases. Each patient was evaluated with Neer's limited goals rating scale after an average follow-up of 33 months (24 to 55 months). Ten patients were rated as successful and six as unsuccessful. Four of the six unsuccessful patients had undergone at least one attempt at rotator cuff repair with acromioplasty before the index procedure, and two of these four patients had deficient deltoid function after this rotator cuff surgery as a result of postoperative deltoid detachment. Also, three of these four patients who had previously undergone acromioplasty subsequently had anterosuperior subluxation after hemiarthroplasty. Hemiarthroplasty did not provide for a successful outcome in all patients with rotator cuff arthropathy. However, 10 of the 12 patients in this series with good deltoid function and an adequate coracoacromial arch were rated as successful by Neer's limited goals criteria. In addition, this study illustrates that formal acromioplasty carried out during attempts at rotator cuff repair in such patients may jeopardize the subsequent success of hemiarthroplasty.

Humeral head osteonecrosis: clinical course and radiographic predictors of outcome

Forty-two patients (65 shoulders) with osteonecrosis of the humeral head were reviewed. Minimal follow-up was 2 years or until shoulder arthroplasty was performed for persistent severe pain and disability not responsive to conservative treatment. Thirteen shoulders had surgery shortly after presentation, whereas 22 others initially treated conservatively required surgery. Thirty shoulders in 20 patients have been treated without surgery and were evaluated at an average of 10 years after initial presentation. Fifteen shoulders are doing satisfactorily, whereas 15 others are doing poorly. Overall, 37 (71%) shoulders had clinical progression of disease requiring shoulder arthroplasty or resulting in severe pain and disability. All had radiographic stage III, IV, or V, and 41 (85%) had articular surface incongruity of 2 mm or greater. Humeral head drilling was not effective in preventing clinical or radiographic progression in stage III.disease. Radiographic stages of III or greater and documented radiographic disease progression were significantly associated with a poor outcome.

The conservative management of the unstable shoulder including rehabilitation

The conservative management of shoulder instability depends on a well-defined program that emphasizes early diminution in the patient's symptoms, appropriate immobilization, and a well-defined precise rehabilitation program that can be individually tailored to meet the patient's needs. Immobilization should be considered in younger patients less than 20 years of age for between 3 to 4 weeks in order to enhance capsulolabral complex healing. Older patients may be immobilized for a shorter period of time. Analgesic medication and local physical therapeutic modalities may be used to decrease the patient's symptomatic complaints. Once the immobilization period has ended, a precise and specific rehabilitation program tailored for the individual needs of the patient should be undertaken. The rehabilitation program should emphasize early and safe regaining of normal ROM, strengthening of the dynamic stabilizers of the shoulder, and strengthening of the scapular stabilizing muscles of the shoulder. Finally, rehabilitation programs that enhance the patient's neuromuscular control over the glenohumeral joint should be considered in the conservative management of the unstable shoulder.

Arthroscopic fixation of superior labral lesions using a biodegradable implant: a preliminary report

Twenty-two patients were treated for symptomatic lesions of the superior glenoid labrum in association with instability of the tendinous insertion of the long head of the biceps brachii. A biodegradable implant was used to fix the labrum to the bony glenoid using an arthroscopic technique. At 2-year average follow-up, satisfactory results were obtained in 86% of the patients. Two patients, both of whom had undergone concomitant subacromial decompression, continued to complain of pain after the procedure; 3 patients had restricted motion postoperatively, and 1 required manipulation under anesthesia. Twelve of 13 overhead athletes were able to return to full premorbid function. Arthroscopic fixation of unstable lesions of the superior labrum led to a resolution of symptoms in the majority of patients. There were no complications related to the use of the biodegradable implant.

Modular shoulder hemiarthroplasty for acute fractures. Surgical considerations

Displaced fractures of the proximal humerus with concomitant comminution, interruption of vascular supply, and articular incongruity often require prosthetic replacement for successful treatment. In these difficult cases, the success of prosthetic replacement is dependent on proper patient selection, appropriate surgical technique, and a well-supervised postoperative rehabilitation program. Careful surgical technique should ensure proper placement of the humeral component at the correct height and version, and proper position and fixation of the displaced tuberosities. Supervised rehabilitation emphasizing early range of motion and strength when the tuberosities have healed improves results. The authors found that a modular design humeral implant allows for improved tensioning of the soft tissues and reconstruction of the tuberosities.

Instability of the shoulder after arthroplasty

A replacement arthroplasty was performed in 236 shoulders at The Hospital for Special Surgery from 1984 through 1989. Ten patients (eight women and two men) from that group were identified as having instability of the shoulder at the time of follow-up, and the results for these patients were reviewed retrospectively. The ages of the patients ranged from fifty-six to seventy-nine years. The instability was anterior in seven of the patients and posterior in three. The anterior instability was caused by a rupture of the repaired subscapularis tendon. The operative treatment of the anterior instability consisted of mobilization and repair of the tendon, but three of the seven patients continued to have instability. A static stabilizer, consisting of an allograft of Achilles tendon, was inserted in these three patients, and the result was a success. The etiology of the posterior instability (three patients) was multifactorial. Treatment consisted of correction of any soft-tissue imbalance and revision of the prosthetic components as necessary. All ten patients were followed clinically and radiographically for at least two years. All of the patients had some loss of motion of the shoulder as compared with the motion before the dislocation. There were no neurovascular complications, problems related to the allografts, or any other complications. We concluded that proper balancing of the soft tissues and positioning of the prosthetic components are essential to a successful arthroplasty of the shoulder. The postoperative rehabilitation should include a physical therapy program in which the range of motion of the arm that was achieved in the operating room is not exceeded.(ABSTRACT TRUNCATED AT 250 WORDS)

Posttraumatic changes of the proximal humerus: Malunion, nonunion, and osteonecrosis. Treatment with modular hemiarthroplasty or total shoulder arthroplasty

Since 1986, 20 shoulder orthroplasties have been performed for chronic, posttroumatic changes of the proximal humerus with a modular prosthetic system. The average patient follow-up was 33 months, range 24 to 47 months. Sixteen women and four men with an average age of 69.6 years were studied. The procedure was carried out for malunion of the tuberosities or humeral head in eight patients, nonunion of the humeral head in six patients, osteonecrosis in three patients, and chronic impression fractures associated with dislocations of the humeral head in three patients. Fair, good, or excellent results were achieved in 90% of patients. The average postoperative motions were forward elevation, 111°; external rotation, 30°; and internal rotation to L2. Two failures occurred. One patient had nonunion of a tuberosity repair with superior instability and secondary impingement requiring revision surgery. A second patient had a postoperative neuropothy and posterior subluxotion with poor function. Patients younger than 70 years of age and those who did not require tuberosity osteotomy had better results. The success of orthroplasty in these difficult occurrences is dependent upon appropriate patient selection, extensive preoperative evaluation, strict attention to surgical detail, and postoperative rehabilitation. Avoidance of tuberosity osteotomy, when feasible, is advised. A modular design has advantages because it facilitates soft-tissue tensioning and tuberosity repair.

Modular hemiarthroplasty for fractures of the proximal part of the humerus

A new biomodular prosthesis was used for the treatment of a displaced fracture of the proximal part of the humerus in twenty-two shoulders in twenty-two patients. The fractures were classified according to the Neer system; there were thirteen four-part, five three-part, and four head-splitting fractures. There were fifteen women and seven men, and the mean age was seventy years (range, forty-nine to eighty-seven years). The hemiarthroplasty was performed an average of eleven days (range, one to forty-five days) after the injury. The deltopectoral interval was used in all patients, and the prosthesis was implanted with cement in twenty of the shoulders. All of the patients participated in a supervised program of rehabilitation. The patients were followed for an average of thirty-six months (range, twenty-six to forty-nine months). Twenty of the twenty-two patients had a good or excellent result. The active forward elevation averaged 119 degrees; external rotation, 40 degrees; and internal rotation, to the twelfth thoracic vertebra. All of the patients except for the two who had a poor result had satisfactory relief of pain. The two patients who had a poor result had a successful revision with a modular prosthesis of the same design. The modular head could be removed, enabling the surgeon to gain access to the glenoid and to adjust the soft tissues. The over-all scores correlated inversely with the age of the patients and the interval from the injury to the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

The coracoid impingement syndrome

Coracoid impingement results from encroachment on the coracohumeral space, presenting as anterior shoulder pain and clicking, particularly in forward flexion, medial rotation, and adduction. In eight shoulders in seven patients, coracohumeral decompression by excision of the lateral 1.5 cm of the coracoid with re-attachment of the conjoined tendon gave pain relief in all, and complete relief in six. This procedure is described and recommended.

Total knee arthroplasty in patients with psoriasis

Patients with progressive psoriasis have an increased infection rate when having total joint arthroplasty. Therefore, maximum precautions should be taken in the perioperative period as well as with long-term follow-up care to prevent joint sepsis in these patients. In particular, skin care should be meticulous. Special attention should be given to use of a topical corticosteroid or other dermatologic treatment when total joint arthroplasty is considered.

Isolated dorsomedial dislocation of the first ray at the medial cuneonavicular joint of the foot: a rare injury to the tarsus. A case report

An isolated dorsomedial dislocation of the medial cuneiform and first ray at the medial cuneonavicular joint in a 37-year-old woman was reduced easily under general anesthesia. The reduction was stable. Early diagnosis, including comparative roentgenographic views and expeditious treatment are essential for recovery of normal function.

Supracondylar osteotomy in thalassemia

The skeletal system manifestations of thalassemia are characterized by severe osteoporosis, frequent fractures and delayed healing. Permanent deformity and disability can complicate the fractures. Surgical correction of deformity by osteotomy of severely osteoporotic bone and immobilization without internal fixation was successful in a 20-year-old woman. While operative correction of deformity is not routinely recommended, the good experience with this case suggests that similar orthopedic procedures can be included in the treatment of thalassemia.

Fractures in thalassemia

Fractures occur frequently in patients with homozygous beta-thalassemia. A study was made of the fractures noted in a group of patients who were followed at the Thalassemia Clinic at The New York Hospital-Cornell Medical Center. Results indicate that these patients often sustain fractures which are multiple and which frequently heal with resultant deformities.