Detached deltoid during arthroscopic subacromial decompression

Radiofrequency in arthroscopic shoulder surgery: a systematic review

BACKGROUND

Radiofrequency has seen an increase in use in orthopedics including cartilage lesion debridement in the hip and knee as well as many applications in arthroscopic shoulder surgery. The purpose of this systematic review is to evaluate the safety and usage of radiofrequency in the shoulder.

METHODS

This systematic review was registered with PROSPERO (international registry) and followed the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines. Embase and PubMed were searched using: "shoulder," "rotator cuff," "biceps," "acromion" AND "monopolar," "bipolar," "ablation," "coblation," and "radiofrequency ablation." The title and abstract review were performed independently. Any discrepancies were addressed through open discussion.

RESULTS

A total of 63 studies were included. Radiofrequency is currently utilized in impingement syndrome, fracture fixation, instability, nerve injury, adhesive capsulitis, postoperative stiffness, and rotator cuff disease. Adverse events, namely superficial burns, are limited to case reports and case series, with higher-level evidence demonstrating safe use when used below the temperature threshold. Bipolar radiofrequency may decrease operative time and decrease the cost per case.

CONCLUSIONS

Shoulder radiofrequency has a wide scope of application in various shoulder pathologies. Shoulder radiofrequency is safe; however, requires practitioners to be cognizant of the potential for thermal burn injuries. Bipolar radiofrequency may represent a more efficacious and economic treatment modality. Safety precautions have been executed by institutions to cut down patient complications from shoulder radiofrequency. Future research is required to determine what measures can be taken to further minimize the risk of thermal burns.

Morphology of the Undersurface of the Anterolateral Acromion and Its Relationship to Surrounding Structures

Background:

A better understanding of the morphology underneath the acromion is needed to prevent complications after arthroscopic subacromial decompression. The precise correlations between the morphologic features underneath the acromion and the surrounding structures including the attachment of the coracoacromial ligament (CAL) and the origin of the deltoid middle head have not yet been determined in the absence of artifacts on the bony surface caused by dissection techniques. Moreover, anatomic findings in previous studies using only older-aged cadavers or dried bones may not reflect the morphologic features of younger and healthy specimens.

Purpose:

To characterize the anterolateral structures morphologically in the inferior aspect of the acromion, assess the relationships of these structures with surrounding structures without dissection artifacts on the bony surface, and verify the cadaveric data in the asymptomatic shoulders of living middle-aged patients.

Study Design:

Descriptive laboratory study.

Methods:

We initially analyzed the relationship between the morphology of the anterolateral structures and surrounding structures in 18 cadaveric shoulders (mean age, 81.8 years), 15 of which were subjected to macroscopic investigation of the CAL attachment and 3-dimensional micro—computed tomography investigation with radiopaque markers and 3 of which were subjected to histologic examination. We also analyzed the morphology underneath the anterolateral acromion in 24 asymptomatic shoulders of middle-aged patients (mean age, 54.8 years) to verify the cadaveric data. In both the cadaveric shoulders and the asymptomatic shoulders of live patients, the long axis, width, and height of the anterolateral prominence were measured by use of 3-dimensional CT imaging.

Results:

In cadavers, the anterolateral prominence underneath the acromion corresponded to the attachment of the CAL. Histologic evaluation revealed that the CAL was continuous to the deep layer of the deltoid middle head in the lateral acromion. The study in asymptomatic shoulders of middle-aged patients revealed bony prominences similar to those observed in cadavers.

Conclusion:

The anterolateral prominence, which corresponds to the attachment of the CAL below the acromion, may be a native structure below the acromion. Moreover, the CAL is continuous to the deep layer of the deltoid middle head in the lateral acromion.

Complete distal deltoid muscle detachment: a case report

BACKGROUND

 The deltoid is a large triangular muscle at the shoulder. It attaches proximally to the clavicle, acromion and scapula, while distally it attaches to the lateral deltoid tuberosity. Ruptures are rare, and the literature only reports cases of proximal detachment. In this article, we report the first case of distal traumatic deltoid muscle detachment and its successful management.

CASE

 A young female sustained a traumatic injury following a Jet Ski accident with loss of consciousness. A complete distal rupture of the deltoid muscle was diagnosed after the basic functions were regained and a thorough musculoskeletal examination could be conducted. A conservative approach helped her to regain an acceptable shoulder function, but there was persistent pain upon activity and cosmetic scarring. The patient underwent surgical reconstruction. Postoperatively, she recovered satisfactorily.

DISCUSSION

 Distal detachment of the deltoid muscle is rare. The choice for surgical treatment may be undertaken based on several factors including functional status and patient-based assessment.

Massive irreparable rotator cuff tear and associated deltoid tear. Does the reverse shoulder arthroplasty and deltoid repair be a possible option of treatment?

BACKGROUND AND PURPOSE

Rupture of the anterior and middle deltoid muscle associated with rotator cuff tear arthropathy (RCA) could result in a definitive loss of shoulder function. The purpose of this study was to evaluate clinical outcomes after a concomitant reverse shoulder arthroplasty (RSA) and deltoid repair under these circumstances.

MATERIALS AND METHODS

Between 2006 and 2012, 18 consecutive patients with a mean age of 69.7 years, affected by massive irreparable rotator cuff tear and associated dehiscence or rupture of anterior and middle deltoid muscle underwent this operation through a modified anterosuperior approach. Four patients referred a previous shoulder surgery and deltoid tear was iatrogenic. The other 14 cases had an attritional deltoid tears. The average follow-up was 64 months (range 25-121 months).

RESULTS

The mean active anterior elevation passed from a preoperative mean of 53 ± 9.1 (range 45-70) to 132.7 ± 11.6° (85-155°), active external rotation passed from a preoperative mean value of 22.4 ± 3.6° (range 18-26) to an average of 33.7 ± 4.7° (range 30-40°). Mean Constant score increased from 42 ± 6.1 (range 31-51) pre-operatively to 72.3 ± 8.2 (range 57-82) post-operatively. At final review, deltoid contour subjectively was satisfactory to all patients with no palpable defects.

CONCLUSION

RSA associated with a repair of deltoid tear could be a viable surgical option in cases of tear involving the anterior and middle deltoid associated with a RCA. Patient with a preoperative chronic axillary nerve neuropathy associated with a deltoid muscle tear should be cautioned about the possibility of lower functional outcomes.

Reverse total shoulder arthroplasty with combined deltoid reconstruction in patients with anterior and/or middle deltoid tears

BACKGROUND AND HYPOTHESIS

Deltoid disruption has traditionally been an absolute contraindication to performing a reverse total shoulder arthroplasty (RTSA), and options available to patients have been limited. We present a series of patients with deltoid tears that underwent concomitant RTSA with deltoid reconstruction. We hypothesize that this combined procedure provides an acceptable, functional alternative for this complex patient population.

MATERIALS AND METHODS

We retrospectively identified all patients who were treated by a single surgeon with a concomitant RTSA and deltoid reconstruction from 2004 to 2012 with minimum 24-month follow-up. Six shoulders in 5 patients met these criteria. The mean age was 69 years (range, 61-79 years), and the mean follow-up period was 76.8 months (range, 24-133 months). We compared preoperative and postoperative range of motion and Penn Shoulder Scores, including subscores, using paired t tests.

RESULTS

Mean forward elevation and external rotation increased from 48° and 12°, respectively, to 120° and 22°, respectively. Penn scores increased from 45.2 to 77.8 postoperatively (P = .03). The Penn satisfaction subscore, in particular, improved from 1.1 (of 10) to 9.0 (P = .005). There was a low rate of recurrent deltoid failure (1 of 6 shoulders), and there were no infections or revisions.

DISCUSSION

Deltoid reconstruction at the same time as RTSA is a viable treatment option as a salvage procedure for patients with deltoid deficiency who otherwise need RTSA for treatment of massive rotator cuff deficiency. In this small series, simultaneous RTSA and deltoid reconstruction resulted in a functional shoulder with a high level of satisfaction and good motion.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

Arthroscopically assisted mini-deltopectoral rotator cuff repair

This study examined the technique and outcome of arthroscopically assisted mini-deltopectoral rotator cuff repair. The mini-deltopectoral approach enables the repair of large or massive rotator cuff tears while preventing injury to the deltoid muscle and axillary nerve often caused by splitting and excessive traction during conventional mini-open repair. This technique also is useful in the repair of subscapularis tears and thus could extend the indications for mini-open repair.

Complication et prévention de l'arthroscopie du membre supérieur

Arthroscopy for upper limb joints disorders has been used increasingly over the past two decades, and is often considered by population as minor surgery. It would be a mistake to mask potential complications, even if they are less important than equivalent conventional technique. Complications depend on the joint, and despite the relative lack of experience for wrist and small joints, elbow arthroscopy seems to be the arthroscopic technique with most important complication rate. However, most of these complications remain minor and curable. Teaching of anatomy and arthroscopic techniques, respect of elementary prudence rules, should allow to control the risk and the learnig curve. Clear and honest information about potential complications provided to patient is certainly the best way to reduce consequences of these complications.

Complications associated with arthroscopic shoulder surgery

We review the literature on complication of arthroscopic shoulder surgery and their management. Computer data based searches were used to identify articles regarding complications of shoulder arthroscopy, as well as hand searches of Arthroscopy and Journal of Shoulder and Elbow Surgery over the last decade. Arthroscopic shoulder surgery has become a popular therapeutic and diagnostic procedure during the past two decades. As with all interventions complications can occur which require recognition and management by the orthopedic surgeon. While the literature is helpful with identifying types of complications, establishing the rate of these complications remains elusive. These complications can be divided into general complications, complications generic to all shoulder procedures, and complications specific to the type of procedure performed. General complications such as infection and anesthesia problems continue to show low incidences. Shoulder arthroscopy presents increased risk of complications over knee arthroscopy in regard to vascular and neurologic injury, fluid extravasation, stiffness, iatrogenic tendon injury, and equipment failure. New techniques of increased complexity for subacromial surgery, rotator cuff repair, and arthroscopic instability present new problems related to implant failure, nerve injury, iatrogenic fracture, and capsular necrosis. While the rate of complications especially with newer procedures remain elusive, most studies suggest that the rate is low, 5.8-9.5% in all recent review studies published. Underreporting complications makes assessment of incidence rates of complication difficult. Proper patient selection, attention to operative detail, and careful post-operative monitoring can minimize the morbidity associated with these complications.