The current standard of the shoulder trauma series in Ireland - A national audit

OBJECTIVES/AIMS

The primary aim of this study was to assess the current standard of shoulder radiographs in Ireland. The secondary aim of this study was to determine whether orthopaedic surgeons in Ireland are of the opinion that a national protocol is required, and what this protocol should consist of.

METHODS

A national audit of shoulder trauma series x-rays performed in emergency departments was conducted. The number and type of views performed was recorded. The anteroposterior (AP) and axillary or Velpeau views were assessed to determine if they met pre-defined audit criteria. Consultant orthopaedic surgeons working in public trauma hospitals were invited to participate in an online survey by email.

RESULTS

The number of shoulder trauma series included in this audit was 789. The majority of patients had two views performed (75.92%, n ​= ​599) and 21.17% (n ​= ​167) had an axillary or Velpeau view. The AP view met the audit criteria in 23.09% (n ​= ​181) of cases. The survey response rate was 70.8% (n ​= ​17). 88.2% (n ​= ​15) of surgeons agreed that three views should be performed for a shoulder trauma series and 94.12% (n ​= ​16) agreed that an axillary or Velpeau view should be included. The majority of surgeons surveyed (94%, n ​= ​16) are in favour of establishing a national protocol.

CONCLUSION

The current standard shoulder trauma series in Irish hospitals consists of two views, most frequently a thoracic AP and a scapular Y view. We propose the introduction of a national protocol consisting of three views: Grashey AP, Scapular Y, and an axillary or Velpeau view.

MRI findings of traumatic and degenerative rotator cuff tears and introduction of the "cobra sign"

Background

A rotator cuff tear (RCT) is a common shoulder diagnosis and its etiology may be acute, traumatic, or chronic degenerative. Differentiation between the 2 etiologies may be important for multiple reasons, but remains difficult based on imaging. Further knowledge about radiographic and magnetic resonance findings to distinguish traumatic from degenerative RCT is needed.

Methods

We analyzed magnetic resonance arthrograms (MRAs) of 96 patients with traumatic or degenerative superior RCT, which were matched according their age and the affected rotator cuff muscle into the 2 groups. Patients older than 66 years of age were excluded from the study to avoid including cases with pre-existing degeneration. In the case of traumatic RCT, the time between the trauma and MRA had to be less than 3 months. Various parameters of the supraspinatus (SSP) muscle-tendon unit were assessed (tendon thickness, presence of a remaining tendon stump at the greater tubercle, magnitude of retraction, layer appearance). The retraction of the 2 SSP layers were individually measured to determine the difference of retraction. Additionally, edema of the tendon and muscle, the tangent- and kinking-sign as well as the newly introduced Cobra-sign (bulging of the distal part of the ruptured tendon with slim configuration of the medial part of the tendon) were analyzed.

Results

Edema within the SSP muscle (sensitivity 13%, specificity 100%, P = .011) or the tendon (sensitivity 86%, specificity 36%, P = .014) are more frequent in traumatic RCT. The same association was found for the kinking-sign (sensitivity 53%, specificity 71%, P = .018) and the Cobra sign (sensitivity 47%, specificity 84%, P = .001). Even though not statistically significant, tendencies were observed toward thicker tendon stumps in traumatic RCT, and greater difference in retraction between the 2 SSP layers in the degenerative group. The cohorts had no difference in the presence of a tendon stump at the greater tuberosity.

Conclusion

Muscle and tendon edema, as well as tendon kinking appearance and the newly introduced cobra-sign are suitable MRA parameters to distinguish between traumatic and degenerative etiology of a superior RTC.

Arthroscopic approach does not yield better results than open surgery after subscapularis repair: a systematic review

PURPOSE

This study aimed to compare the long-term outcomes of arthroscopic versus mini-open repair in patients with isolated subscapularis tendon tears.

METHODS

Google Scholar, PubMed, and Embase databases were searched for studies evaluating isolated subscapularis tears subsequently treated by arthroscopic or mini-open repair. The inclusion criteria were clinical studies reporting isolated subscapularis lesions treated by arthroscopic or mini-open repair, a minimum follow-up of 12 months, and clinical and functional outcomes reported in the study results. Articles not reporting functional outcomes or studies that reported results for anterosuperior rotator cuff tears without a separate analysis of subscapularis tendon tears were excluded. Studies older than 20 years and studies with a minimum follow-up of less than 12 months were also excluded.

RESULTS

A total of 12 studies met the inclusion criteria; 8 papers were included in the arthroscopic repair group, and 6 were included in the mini-open repair group (2 studies reported results for both techniques). The mean age reported was 49.3 years, and 85.1% of patients were male. The dominant limb was involved in 77.6% of the patients, and a traumatic onset of symptoms was verified in 76.3%. The mean time to surgery was 9.6 months. The Constant-Murley score showed positive results for the arthroscopic and mini-open groups, with mean postoperative values of 84.6 and 82.1, respectively. Promising results were also observed for pain, with a mean of 13.2 (out of 15) points for the arthroscopic group and 11.7 for the mini-open group. The long head of the biceps was involved in 78% of the patients, and LHB tenodesis or tenotomy were the most common concomitant procedures performed.

CONCLUSIONS

There was no significant difference in clinical and functional outcomes between open and arthroscopic repair. Moreover, the same complication rates were reported in both treatments, but arthroscopic repair led to less postoperative pain.

LEVEL OF EVIDENCE

IV.

A prospective randomized controlled trial comparing plating augmented with coracoclavicular fixation and hook plate fixation of displaced distal-third clavicle fractures

BACKGROUND

Two popular methods used to treat distal-third clavicle fractures are the traditional hook plate and the anatomically contoured locking plate. No consensus exists on whether one method is more effective than the other. Therefore, the aim of this study was to compare the efficacy of a traditional hook plate with that of an anatomically contoured locking plate augmented with coracoclavicular fixation in the treatment of distal-third clavicle fractures.

METHODS

Enrolled patients were randomly assigned to either the hook plate group (n = 13) or the locking plate group (n = 17). Follow-up assessments (clinical and radiologic) were performed at 6 and 12 months postoperatively.

RESULTS

In both groups, union was achieved in 91% of cases at 6 months and 100% at 12 months. No differences in Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley shoulder scores were noted between the hook plate and locking plate groups at 12 months. From 6 to 12 months, DASH scores improved in the hook plate group (P = .007) and Constant-Murley shoulder scores tended to improve (P = .075). Surgical time was longer in the locking plate group than in the hook plate group (P < .001).

CONCLUSION

Similar functional outcomes and union rates were achieved in both groups at 12 months postoperatively. However, the improvement in DASH scores in the hook plate group from 6 to 12 months suggests that patients treated with an anatomically contoured locking plate make a quicker recovery than patients treated with a hook plate.

Shoulder injuries from birth to old age: A 1-year prospective study of 3031 shoulder injuries in an urban population

INTRODUCTION

Shoulder injuries are commonly encountered in emergency departments. In spite of this, the epidemiology is only partly known, and soft tissue injuries in particular remain unclear. The aim of this study was to obtain an overview of shoulder injuries in a general population cohort, and to estimate the relative proportion of the main injury categories soft tissue injuries, fractures and dislocations, as well as their variation with age and gender.

PATIENTS AND METHODS

We registered prospectively all patients admitted with a suspected shoulder injury at a combined casualty and primary health care facility during one year. The facility serves all hospitals and all citizens of Oslo. The patient-reported questionnaires, electronic patient records and radiology reports were examined.

RESULTS

3031 shoulder injuries were registered from May 2013 through April 2014. The median age was 37 years (range 14 days-102 years), 51 years in women and 31 years in men (p < 0.001), 60% were male. The male/female shoulder injury incidence rate ratio in the 20-34 years age group was 3.6 (95%CI, 3.0 to 4.3; p < 0.001). Contrary, the female/male rate ratio above 75 years was 2.1 (95%CI, 1.6-2.8; p < 0.001). Almost half of the injuries were soft tissue injuries, 35% were fractures and 17% were dislocations. The age-stratified incidence rates differed substantially in men and women. Fractures dominated in children up to 10 years and in adults over 60 years, soft tissue injuries in the ages between. The highest dislocation incidence rates were found in young males. A rotator cuff tear was diagnosed in 4% of the injuries.

CONCLUSION

Which shoulder structures that are affected by injury vary substantially with age and gender. The shoulder injury incidence rates of young men and the elderly are high. The findings are important for the understanding of the shoulder and the diagnostic process in A&Es.

[Simultaneous fracture of the acromion and coracoid process : Rare variant of double disruption of the superior shoulder suspensory complex]

INTRODUCTION

Simultaneous fracture of the acromion and coracoid process represents a double disruption of the superior shoulder suspensory complex (SSSC). To date, the two largest reported series have comprised five and eight cases. The aim of this study was to investigate the functional outcome in patients who sustained this rare injury and to provide a review of the relevant literature.

MATERIAL AND METHODS

In this retrospective study, patients who were surgically treated between 2009 and 2014 were identified from medical records and the patients were asked to attend a follow-up examination. Functional results, measured as the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score, were the main outcomes of the study.

RESULTS

A total of six patients underwent surgery for this type of double disruption of the SSSC. All but one patient suffered a high-impact trauma with other associated injuries. The coracoid fracture was classified as type I according to Ogawa in all cases, and the acromion fracture was type III according to Kuhn in 5 out of 6 cases. At least one of the fracture sites was stabilized. Of the patients one showed a concurrent lateral clavicle fracture, representing a third disruption of the SSSC, and another had a fracture of the medial third of the clavicle, representing a strut fracture. In these cases, two fracture sites were operated on. At an average follow-up period of 47 months all but one fracture had healed. In one patient, asymptomatic non-union of the acromion was found. The average DASH score was 22 points and the average Constant score was 74 points.

CONCLUSION

This rare injury pattern is usually caused by high-impact trauma, and concomitant injuries frequently occur. Nevertheless, surgical stabilization of at least one of the fracture sites showed satisfactory functional results.

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures

INTRODUCTION

The purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation.

METHODS

A total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection.

RESULTS

Forty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142±17.0° and AER was 41±13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2±20.0 and average Constant score was 72.7±17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p=0.297) or varus collapse (p=0.95) were not associated with an increased likelihood of sustaining a complication.

CONCLUSIONS

Follow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.

Hertel 7 fracture of the humeral head. Can two different fixation systems (Diphos/PHP) lead to different outcomes? A retrospective study

OBJECTIVE

To compare clinical outcomes and complication rates in the medium-to-long-term follow-up of Hertel 7 humeral head fractures treated with two different locking plates.

MATERIALS AND METHODS

A total of 52 patients with type 7 humeral head fracture (in accordance with Hertel classification) were enrolled retrospectively: 24 patients [4 male, 20 female; mean age (standard deviation [SD]): 68.9 (5.8) years] were treated with Diphos H plate (Group A) and 28 patients [6 male, 22 female; mean age (SD): 61.0 (7.5) years] with Proximal Humeral Plate (PHP; Group B). The mean follow-up periods were 25.6 and 18.9 months, respectively. Functional outcomes were assessed using the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score; X-ray evaluation was also performed and complications were recorded.

RESULTS

The mean Constant score in the Diphos and PHP groups at follow-up were 75.6 (SD 13.4) and 78.9 (SD 12.8), respectively (p>0.05). The DASH score was similar in both groups (Diphos: 18.6, range 0-51.5; PHP: 16.8, range 0-47.8) (p>0.05). In our series, 9.6% of patients had complications; these included a case of aseptic non-union and a case of avascular necrosis of the humeral head in each group, and a secondary screw perforation in a patient treated with Diphos.

CONCLUSIONS

In patients with Hertel 7 proximal humeral fractures, Diphos and PHP lead to similar satisfactory functional outcomes and are associated with low complication rates; this confirms that both are useful implants for the treatment of this pattern of fracture.

Differences in acromial morphology of shoulders in patients with degenerative and traumatic supraspinatus tendon tears

PURPOSE

Distinct characteristics of acromial morphology seem to be one factor for the development of degenerative supraspinatus tendon tears. Thus, it is questionable whether patients with traumatic tendon tears also present these parameters. The hypothesis of the present study was that the acromial morphology of patients with degenerative supraspinatus tendon tears differs from patients with traumatic tears.

METHODS

One hundred and thirty-six patients that were treated by arthroscopic rotator cuff repair from 2010 to 2013 were included in this study. Seventy-two patients had degenerative (group 1), and 64 had traumatic (group 2) supraspinatus tendon tears. On preoperative radiographs the Bigliani type, acromial slope, acromiohumeral (AH) distance, lateral acromial angle (LAA), acromion index (AI), and critical shoulder angle (CSA) were measured. Medians of these parameters as well as of age of both groups were compared using the t test.

RESULTS

The percentaged distribution of the Bigliani type differed (group 1 vs. 2: type 1: 18/38, type 2: 56/55, type 3: 26/8). All parameters showed significant differences between degenerative and traumatic tears. Slope: 21.2° (SD 7.6°) versus 19.2° (SD 7.9°, p = 0.026), AH distance: 8.4 mm (SD 2.3 mm) versus 9.9 mm (SD 1.9 mm, p = 0.0006), LAA: 77.0° (SD 4.0°) versus 82.5° (SD 4.7°, p < 0.0001), AI: 0.77 (SD 0.07) versus 0.73 (0.06, p = 0.0239), and CSA: 36.8° (SD 3.6°) versus 35.3° (SD 2.9°, p = 0.007). An LAA <70° or an AH distance of <5 mm only occurred in degenerative tears. Patients with degenerative tears were significantly older (60 vs. 54 years).

CONCLUSIONS

The hypothesis that the acromial morphology of patients with degenerative supraspinatus tendon tears differs from patients with traumatic tears was confirmed. Shoulders with degenerative tears show a narrower subacromial space and a larger lateral extension as well as a steeper angulation of the acromion than with traumatic tears. Thus, the results of this study support the theory of external impingement as a cause for degenerative rotator cuff tears.

LEVEL OF EVIDENCE

IV.

Moderate value of non-contrast magnetic resonance imaging after non-dislocating shoulder trauma

PURPOSE

The purpose of the present study was to determine the value of shoulder magnetic resonance imaging (MRI) obtained in the community setting interpreted by musculoskeletal radiologists in patients with shoulder pain initiated by a single non-dislocating shoulder trauma.

METHODS

In 56 of 61 consecutive patients who underwent shoulder arthroscopy due to pain after a single non-dislocating shoulder trauma, the data sets of non-contrast MRI were complete. These were retrospectively interpreted by three radiologists specialized on musculoskeletal MRI who were blinded for patients' history and who did not have access to the reports of arthroscopy. Standard evaluation forms were used to assess the MRIs for superior labrum anterior and posterior (SLAP) lesions, anterior or posterior labrum lesions, lesions of the long head of biceps tendon (LHB) and for partial tears of the supraspinatus tendon and the upper quarter of the subscapularis tendon. Quality of the MRI was assessed by each radiologist on a four-point scale.

RESULTS

The pooled sensitivity for the three radiologists for the detection of SLAP lesions was 45.0 %, for anterior or posterior labrum tears 77.8 and 66.7 %, for lesions of the LHB 63.2 % and for partial tears of the supraspinatus or subscapularis tendon tears 84.8 and 33.3 %. Corresponding inter-rater reliabilities were poor (SLAP lesions) to substantial (anterior labrum tears). Quality of MRI only influenced the accuracy for the detection of posterior labrum tears.

CONCLUSION

A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists. Accuracy is dependent on the observer and not on the assessed quality.

LEVEL OF EVIDENCE

Case series, Level IV.

Shoulder hemiarthroplasty for complex humeral fractures: a 5 to 10-year follow-up retrospective study

BACKGROUND

Shoulder hemiarthroplasty is considered a standard treatment in case of complex proximal humeral fractures. However, great variability affects the clinical outcomes. In this work, we examined the clinical and radiographic outcomes in a series of patients treated with hemiarthroplasty for 3- and 4-part humeral fractures and focused on factors affecting the final result.

MATERIALS AND METHODS

In this study, we included 27 patients who had received a shoulder hemiarthroplasty between 2001 and 2005 at our institution. These patients were evaluated at an average of 7.2 years after surgery. All patients were managed within 10 days from trauma by the same surgeon and underwent the same time-scheduled rehabilitation program. Average age at surgery was 71.9 years.

RESULTS

Implant survival was 88.9 %. At the latest follow-up, mean DASH and SST-12 scores were 26.8 and 6.5, respectively. Mean Constant-Murley score was 52.4. Tuberosities complications and reduction in the acromion-humeral distance were negatively related to clinical outcome. Age at surgery displayed a negative correlation with clinical outcome, despite not reaching the statistical significance. This is mainly due to great variability in the elder group of patients.

CONCLUSIONS

Shoulder hemiarthroplasty is a useful and effective solution for complex humeral fractures, with good results in the majority of patients. However, outcomes display a great variability in relation to X-ray alterations and age at surgery. A careful attention in patient selection is needed in order to standardize the clinical results associated with this kind of prosthetic implant.

Shoulder fusion after a self-inflicted gunshot wound: an injury pattern and treatment option

Gunshot injuries to the shoulder are rare and difficult to manage. We present a case series of seven patients who sustained a severe shoulder injury to the non-dominant side as a result of a self-inflicted gunshot wound. We describe the injury as 'suicide shoulder' caused by upward and outward movement of the gun barrel as the trigger is pulled. All patients were male, with a mean age of 32 years (21 to 48). All were treated at the time of injury with initial repeated debridement, and within four weeks either by hemiarthroplasty (four patients) or arthrodesis (three patients). The hemiarthroplasty failed in one patient after 20 years due to infection and an arthrodesis was attempted, which also failed due to infection. Overall follow-up was for a mean of 26 months (12 to 44). All four hemiarthroplasty implants were removed with no feasible reconstruction ultimately possible, resulting in a poor functional outcome and no return to work. In contrast, all three primary arthrodeses eventually united, with two patients requiring revision plating and grafting. These patients returned to work with a good functional outcome. We recommend arthrodesis rather than replacement as the treatment of choice for this challenging injury.