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Malige A, Tibone JE, Hui A, Kwak D, Jewell J, McGarry MH, Lee TQ. A Biological Spacer to Treat Irreparable Rotator Cuff Tears: A Biomechanical Study Utilizing a Secured Versus Unsecured Tensor Fascia Lata Graft. Am J Sports Med 2024; 52:2092-2100. [PMID: 38822576 DOI: 10.1177/03635465241252140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Abstract
BACKGROUND Designed to help treat pain and loss of function after rotator cuff repair, allograft spacer procedures utilize a graft to act as a spacer in the subacromial space, decreasing pain from impingement of the greater tuberosity on the acromion at the extremes of overhead motion. PURPOSE To evaluate the biomechanical characteristics of secured versus unsecured tensor fascia lata allografts used in an allograft spacer procedure. STUDY DESIGN Controlled laboratory study. METHODS A total of 8 fresh-frozen cadaveric shoulder specimens were used. There were 4 conditions tested: (1) intact rotator cuff, (2) stage III rotator cuff tear (complete supraspinatus tendon and superior one-half of the infraspinatus tendon), (3) unsecured tensor fascia lata graft, and (4) secured tensor fascia lata graft. Both superior and posterior translation of the humeral head were calculated in each condition. A 4-cm × 5-cm × 6-mm tensor fascia lata graft was used in the subacromial space to act as a spacer. Grafts were secured at the lateral edge of the native rotator cuff footprint with 2 knotless anchors. RESULTS With unbalanced loading, both secured and unsecured grafts varied in their ability to limit superior and posterior translation at various rotation angles back to levels seen with intact rotator cuffs at 0° and 20° of abduction. During balanced loading, both unsecured and secured grafts limited superior and posterior translation more than those seen in the rotator cuff-deficient condition (P < .01) and similar to those seen in the intact condition (P > .05). The secured and unsecured grafts allowed similar amounts of translation at every position with both unbalanced and balanced loading (P > .05). Finally, total graft motion was <7 mm in all positions. CONCLUSION Unsecured tensor fascia lata grafts were biomechanically equivalent to secured grafts when used during allograft spacer procedures. CLINICAL RELEVANCE While both grafts were successful at limiting superior and posterior translation of the humeral head during early range of motion, the unsecured graft represents a cheaper, easier option to utilize during allograft spacer procedures.
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Affiliation(s)
- Ajith Malige
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - James E Tibone
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Aaron Hui
- Congress Medical Foundation, Pasadena, California, USA
| | - Daniel Kwak
- Congress Medical Foundation, Pasadena, California, USA
| | - Josh Jewell
- Congress Medical Foundation, Pasadena, California, USA
| | | | - Thay Q Lee
- Congress Medical Foundation, Pasadena, California, USA
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Lopez-Fernandez V, Luengo-Alonso G, Valencia M, Martínez-Catalán N, Foruria AM, Calvo E. Comprehensive arthroscopic management without axillary nerve release or subacromial decompression achieves satisfactory and durable results in young patients with glenohumeral osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2023:10.1007/s00167-023-07377-0. [PMID: 37130951 DOI: 10.1007/s00167-023-07377-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 03/01/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE The comprehensive arthroscopic management (CAM) procedure is a useful joint-preserving option for young or active patients with glenohumeral osteoarthritis (GHOA). Our objective was to evaluate the results and prognostic factors of the CAM procedure without direct axillary nerve release or subacromial decompression. METHODS A retrospective observational study among patients with GHOA who underwent the CAM procedure was conducted. Neither axillary nerve neurolysis nor subacromial decompression was performed. Both primary and secondary GHOA were considered; the latter was defined as a history of shoulder pathology (mainly instability or proximal humerus fracture). The American Shoulder and Elbow Surgeons scale, Simple Shoulder Test, Visual Analogue Scale, activity level, Single Assessment Numeric Evaluation, EuroQol 5 Dimensions 3 Levels, Western Ontario Rotator Cuff Index, and active range of motion (aROM) were analysed. RESULTS Twenty-five patients who underwent the CAM procedure met the inclusion criteria. After a mean follow-up of 42.4 ± 22.9 months, we found improvement (p < 0.001) in all postoperative values of the different scales. The procedure increased aROM overall. Patients with arthropathy due to instability showed worse results. The rate of CAM failures, defined as conversion to shoulder arthroplasty, was 12%. CONCLUSIONS This study showed that the CAM procedure without direct axillary nerve neurolysis or subacromial decompression might be a valid alternative in active patients with advanced GHOA to improve shoulder function (aROM and scores), decrease pain, and delay arthroplasty. This technique showed good subjective functional scores, high patient satisfaction, and a low rate of complications. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Vanesa Lopez-Fernandez
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Rey Juan Carlos, Universidad Rey Juan Carlos, Gladiolo, S/N, Mostoles, Madrid, Spain.
| | - Gonzalo Luengo-Alonso
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopaedic Surgery and Traumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - María Valencia
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopaedic Surgery and Traumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Natalia Martínez-Catalán
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopaedic Surgery and Traumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Antonio María Foruria
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopaedic Surgery and Traumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Emilio Calvo
- Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopaedic Surgery and Traumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
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Consensus Statement for Shoulder Impingement: To Operate or Not? Who to Ask for the Consensus Panel. Arthroscopy 2022; 38:1385-1387. [PMID: 35501003 DOI: 10.1016/j.arthro.2022.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/25/2022] [Indexed: 02/02/2023]
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Ando A, Suzuki K, Koide M, Hagiwara Y. Ultrasound-guided Arthroscopic Tuberoplasty for Greater Tuberosity Malunion: A Case Report. Open Orthop J 2020. [DOI: 10.2174/1874325002014010204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:
Greater Tuberosity (GT) malunion can lead to impingement against the acromion, resulting in pain, stiffness, and weakness of the rotator cuff. For patients with lesser degrees of displacement, partial removal of the GT with rotator cuff repair (tuberoplasty) under fluoroscopic guidance is considered.
Case report:
A sixty-five year old female fell from a standing height and suffered a minimally displaced isolated GT fracture. She was conservatively managed for four months and referred to our institution due to persisting pain and stiffness. The shoulder motion was severely restricted (anterior elevation: 90°, lateral elevation: 45°, external rotation with the arm at side: 25°, hand behind back: 4th lumber vertebrae) and pain aggravated especially when laterally elevated. Plain radiography and computed tomography showed small superiorly malunited GT and magnetic resonance imaging showed no rotator cuff pathology. Ultrasound images showed impingement of the GT against the acromion when laterally elevated. Arthroscopic excision of the malunited GT and rotator cuff repair along with capsular release and acromioplasty was performed under ultrasound guidance. The ultrasound images were simultaneously delineated to the arthroscopic monitor. Dynamic evaluation of the reshaped GT passing under the acromion was possible.
Conclusion:
Intraoperative use of ultrasound during arthroscopic tuberoplasty offers advantages over fluoroscopic guidance concerning control of the amount of bone resection and dynamic evaluation between the GT and the acromion in addition to the problems of radiation and space-occupying devices.
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Cunningham G, Nicodème-Paulin E, Smith MM, Holzer N, Cass B, Young AA. The greater tuberosity angle: a new predictor for rotator cuff tear. J Shoulder Elbow Surg 2018; 27:1415-1421. [PMID: 29703680 DOI: 10.1016/j.jse.2018.02.051] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/10/2018] [Accepted: 02/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The implication of scapular morphology in rotator cuff tears has been extensively studied. However, the role of the greater tuberosity (GT) should be of equal importance. The aim of this study was to propose a new radiographic marker, the GT angle (GTA), which measures the position of the GT in relation to the center of rotation of the humeral head. The hypothesis was that a higher angle value would be associated with a higher likelihood in detecting a rotator cuff tear. METHODS During 1 year, patients were prospectively recruited from a single institution specialized shoulder clinic in 2 different groups. The patient group consisted of individuals with a degenerative rotator cuff tear involving at least the supraspinatus. The control group consisted of individuals with no rotator cuff pathology. Individuals in both groups with congenital, post-traumatic, or degenerative alterations of the proximal humerus were excluded. The GTA was measured on an anteroposterior shoulder x-ray image with the arm in neutral rotation by 3 observers at 2 different times. RESULTS The study recruited 71 patients (33 patients, 38 controls). Mean GTA value was 72.5° (range, 67.6°-79.2°) in patients and 65.2° (range, 55.8°-70.5°) for controls (P <.001). A value above 70° resulted in 93-fold higher odds of detecting a rotator cuff tear (P <.001). Interobserver and intraobserver reliability were high. CONCLUSIONS GT morphology is implicated in rotator cuff tears. The GTA is a reliable radiographic marker, with more than 70° being highly predictive in detecting such lesions.
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Affiliation(s)
- Gregory Cunningham
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland; Shoulder Center, Hirslanden Clinique la Colline, Geneva, Switzerland.
| | | | - Margaret M Smith
- Institute of Bone and Joint Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Nicolas Holzer
- Division of Orthopaedic and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Cass
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
| | - Allan A Young
- Sydney Shoulder Research Institute, Sydney, NSW, Australia
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Park SE, Jeong JJ, Panchal K, Lee JY, Min HK, Ji JH. Arthroscopic-assisted plate fixation for displaced large-sized comminuted greater tuberosity fractures of proximal humerus: a novel surgical technique. Knee Surg Sports Traumatol Arthrosc 2016; 24:3892-3898. [PMID: 26419378 DOI: 10.1007/s00167-015-3805-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 09/18/2015] [Indexed: 12/16/2022]
Abstract
PURPOSE The purpose of the present study was to describe the use of a novel hybrid surgical technique-arthroscopic-assisted plate fixation-and evaluate its clinical and anatomical outcomes in the management of large, displaced greater tuberosity (GT) fractures with comminution. METHODS From 2009 to 2011, this novel technique was performed in 11 patients [2 men and 9 women; median age, 64 years (range 41-83 years)] with large, comminuted GT fractures, with fragment displacements of >5 mm. The preoperative mean posterior and superior migration of the fractured fragment, as measured on computed tomography (CT), was 19.5 and 5.5 mm, respectively. Two patients had shoulder fracture-dislocation, and three had associated undisplaced surgical neck fracture. The mean duration between injury and surgery was 4 days. The mean follow-up duration was 26 months. RESULTS At the final follow-up, the mean postoperative ASES, UCLA and SST scores were 84, 29, and 8, respectively. The mean range of motion was as follows: forward flexion, 138°; abduction, 135°; external rotation at the side, 19°; and internal rotation, up to the L2 level. The mean posterior and superior displacements of fracture fragments on postoperative CT scan [0.7 ± 0.8 mm (range 0-2.1 mm) and 2.8 ± 0.5 mm (range 3.4-5.3 mm), respectively] were significantly improved (p < 0.05). On arthroscopy, a partial articular-side supraspinatus tendon avulsion lesion was identified in 10 of 11 patients (91 %), and 1 of these patients had a partial tear of the biceps and 1 had a partial subscapularis tear, respectively (9 %). Intraoperatively, 1 anchor pullout and 1 anchor protrusion through the humeral head were noted and corrected. Postoperatively, the loss of reduction in the fracture fragment was noted in 1 patient at 4 weeks, after corrective reduction and fixation surgery. CONCLUSIONS The novel arthroscopic-assisted anatomical plate fixation technique was found to be effective in reducing large-sized, displaced, comminuted GT fractures and in allowing concurrent management of intra-articular pathologies and early functional rehabilitation. Compared with the conventional plate fixation or arthroscopic suture anchor fixation technique, arthroscopic-assisted plate fixation enabled accurate restoration of the medial footprint of the GT fracture and provided an effective buttress to the large-sized GT fracture fragments. LEVEL OF EVIDENCE Retrospective clinical study, Level IV.
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Affiliation(s)
- Sang-Eun Park
- Department of Orthopedic Surgery, Daejon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, Korea
| | - Jae-Jung Jeong
- Department of Orthopedic Surgery, Daejon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, Korea
| | - Karnav Panchal
- Department of Orthopedic Surgery, Daejon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, Korea
| | - Jong-Yun Lee
- Department of Orthopedic Surgery, Daejon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, Korea
| | - Hyung-Ki Min
- Department of Orthopedic Surgery, Daejon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, Korea
| | - Jong-Hun Ji
- Department of Orthopedic Surgery, Daejon St. Mary's Hospital, The Catholic University of Korea, 520-2, Deahung-Dong, Joong-Ku, Daejeon, 302-803, Korea.
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Abstract
Proximal humerus fractures remain one of the most common orthopaedic injuries, particularly in the elderly. Displaced fractures often require surgery, and management can be challenging because of comminution and poor bone quality. Despite advances in surgical technique and implant design, reoperation for malunion or nonunion of the tuberosity (arthroplasty) or screw penetration (open reduction and internal fixation) remains problematic. Recent studies have demonstrated acceptable results following nonsurgical management of displaced proximal humerus fractures in elderly, low-demand patients. In younger, more active patients, reduced function and pain that accompany select proximal humeral malunions are generally poorly tolerated. Surgical options for symptomatic, malunited tuberosities include osteotomy, tuberoplasty with rotator cuff repair and subacromial decompression, or decompression alone. Surgical neck malunion can be managed with corrective osteotomy and preservation of the native joint. Arthroplasty is reserved for complex malunions with joint incongruity. Surgical management of symptomatic proximal humeral malunion remains challenging, but good outcomes can be achieved with proper patient selection.
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My shoulder is stuck. Limited range of motion after open reduction and internal fixation of the shoulder. CURRENT ORTHOPAEDIC PRACTICE 2014. [DOI: 10.1097/bco.0000000000000115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Arthroscopic refixation of a combined fracture of the greater and lesser tuberosity of the proximal humerus. Knee Surg Sports Traumatol Arthrosc 2013; 21:1171-5. [PMID: 22581195 DOI: 10.1007/s00167-012-2033-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED Combined fractures of the greater and the lesser tuberosity are very rare injuries. This is a case report on arthroscopic treatment using suture anchors and one distal fixation screw. Clinical and radiographic follow-up showed recovery of active motion and consolidation of the fragments in anatomic positions. LEVEL OF EVIDENCE V.
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Lädermann A, Denard PJ, Burkhart SS. Arthroscopic management of proximal humerus malunion with tuberoplasty and rotator cuff retensioning. Arthroscopy 2012; 28:1220-9. [PMID: 22405916 DOI: 10.1016/j.arthro.2011.12.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 12/09/2011] [Accepted: 12/13/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the mid- to long-term results of arthroscopic tuberoplasty and rotator cuff retensioning for proximal humerus malunion. METHODS Between August 2001 and October 2009, 9 patients with a mean age of 49 years underwent shoulder arthroscopy with tuberoplasty and rotator cuff advancement for malunion of the proximal humerus and were included in this study. The mean delay between the initial fracture and our surgery was 19 months. We developed a systematic technique to take down the rotator cuff over the malunited proximal humerus, perform a tuberoplasty, and then retension and repair the rotator cuff by advancing it on the greater tuberosity. The mean follow-up was 50 months (range, 12 to 108 months). RESULTS Patients showed mean active forward elevation of 164° (range, 90° to 180°; gain of 43°), recovery of mean active external rotation of 45° (range, 30° to 60°; gain of 16°), and a mean pain score of 1.8 points (range, 0 to 5 points; reduction of 3.8 points). The overall functional results according to the University of California, Los Angeles score were excellent in 3 cases, good in 3, and fair in 3. No patient required additional surgery. Of the 9 patients, 8 (89%) were able to return to their previous sports or activities. All patients declared themselves as being satisfied with the result. CONCLUSIONS Arthroscopic tuberoplasty and rotator cuff retensioning for proximal humerus malunion comprise a viable alternative to traditional open methods, particularly in young patients. A comprehensive approach is recommended that addresses stiffness, associated pathology, and impingement, and re-establishes rotator cuff function. Although the technique is technically demanding, it allows preservation of the native humeral head, is associated with a very low complication rate, and avoids concerns about long-term prosthetic survival in young patients. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
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Pseudoartrosis y maluniones de húmero proximal. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recot.2011.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Valencia M, Barco R, Antuña S. Pseudoarthrosis and proximal humeral malunions. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recote.2011.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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