Arthroscopic rotator cuff repair with double-row fixation

BACKGROUND

The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique.

METHODS

Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff.

RESULTS

The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores.

CONCLUSIONS

Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair.

LEVEL OF EVIDENCE

Therapeutic Level IV.

About the variability of the shape of the glenoid cavity

The morphology of the glenoid cavity is highly variable, and no consensus exists regarding how to classify the different forms. We examined 98 dry scapulae to identify a common morphological entity and to define reproducible bony references of the glenoid cavity. The glenoid cavities were photographed perpendicularly in a standardized fashion. The bony peripheral rim was studied on these two-dimensional images, defined by randomly chosen points in order to define one or more circles. This study showed that only the peripheral rim of the inferior quadrants of the articular surface was found to be located on a circle ( P=0.926) with a radius of 12.8 mm (SD 1.3 mm). Defining the center of this circle appeared to be more reliable (ICC 0.98) than determining the middle point of the longitudinal axis (0,0) between the most cranial and most caudal points, defined as Saller's line (ICC 0.89). The distance of the center of this projected circle to the middle point of Saller's line had a unimodal distribution, suggesting the existence of only one glenoid cavity morphotype. We then investigated the relationship between the center of the circle and the area of subchondral bone thickening under the bare spot, the so-called tubercle of Assaki. Ten phenolized cadaveric glenoid cavities were examined with computed tomography. A circle was projected on the first image showing the bony peripheral rim, and this circle was copied on the consecutive slices until the tubercle of Assaki came across. The center of the circle was located within the area of the tubercle of Assaki, in all but one specimen. To investigate the clinical implications of this finding, the cadaver specimens were used to compare the position of the center of the circle with the postulated center of implantation according to the literature, and to the reference guide for a commonly used total shoulder prosthesis. The center of the circle was consistently situated more distal than the postulated center of the guide (mean 5.5 mm, range 4-8 mm) and the middle point of the glenoid cavity (mean 2 mm, range 1-3 mm). These findings could offer a reproducible point of reference for the glenoid cavity in osseous anthropometry and a valuable reference in shoulder replacement surgery, and might help in the definition of osseous glenohumeral instability.

Arthroscopic release of adhesive capsulitis

Twenty-five patients with primary adhesive capsulitis underwent an arthroscopic release of the capsule of the shoulder joint. They were reviewed after a mean of 14.8 months (range, 3-40 months). Night pain and awakening were a feature in all 25 patients preoperatively but were only found in 3 postoperatively. There was marked improvement in pain from a preoperative visual analog scale score of 3.1 to a postoperative visual analog scale score of 12.6 on a scale of 15. Passive movement of the joint improved significantly, with mean passive elevation changing from 73.7 degrees preoperatively to 163 degrees postoperatively, mean passive external rotation changing from 10.6 degrees preoperatively to 46.8 degrees postoperatively, and passive internal rotation improving by a mean of 9 levels. The mean preoperative Constant score of 25.3 improved to 75.5 postoperatively, and the Constant score adjusted for age and gender averaged 91%. All patients completed the Short Form-36 questionnaire at their review, revealing a norm-based physical summary score of 48.7, falling within 1 SD of a normal population sample. This arthroscopic surgical technique is derived from the open surgical release. It is founded upon an understanding of the pathology of this condition. It appears to yield rapid relief of pain and dramatic improvement in movement and function in this painful and otherwise protracted condition.

Shoulder prostheses treating cuff tear arthropathy: a comparative biomechanical study

Painful cuff tear arthropathy (CTA) affects the independence of the elderly. Surgical treatment often consists of joint replacement, the functional outcome of which remains variable. Knowledge of the biomechanical properties of the different prosthetic designs can guide the orthopaedic surgeon in the choice of implant to predict its clinical result. A 3-D computer model of the glenohumeral joint is used to analyse the moment of the deltoid muscle in the scapular plane. A geometrical 3-D ball-and-socket model of the shoulder joint was used to calculate (1) the angle-force relationships, (2) the moment arm of the deltoid muscle and (3) the moment of the deltoid muscle components, for increasing degrees of arm elevation in the scapular plane. In this 3-D model, a clinical thoraco-scapular rhythm analysis was implemented, based on measurements in normal subjects, patients treated with an anatomical prosthesis and patients treated with an inversed delta III prosthesis. These data were compared for 10 different prosthetic treatment options.

RESULTS

Muscle angle-force curves show a favourable slope in non-anatomical prosthetic designs, where the centre of rotation of the glenohumeral joint is medialized, the deltoid muscle is elongated and the humeral shaft is lateralized. On the contrary, anatomical prosthetic designs do not perform well in this computer analysis.

CONCLUSIONS

From a biomechanical point of view, a shoulder prosthesis which medializes the centre of rotation, lengthens the deltoid muscle and increases the deltoid lever arm, results in a significantly more powerful abduction of the shoulder, despite complete loss of rotator cuff function.

RELEVANCE

This study explains why a successful functional outcome can be expected in CTA with a reversed prosthesis.

Clinical and radiological outcomes of the Ivory arthroplasty for trapeziometacarpal joint osteoarthritis with a minimum of 5 years of follow-up: a prospective single-centre cohort study

We present the results of a 5 year prospective follow-up study on the functional outcome after total replacement of the trapeziometacarpal joint with the Ivory prosthesis (Memometal, Stryker Corporate, Kalamazoo, Michigan, USA) in 22 patients. The female to male ratio was 21:1 and the mean age was 66 (range 54-78) years. The mean follow-up period was 67 (range 60-77) months after operation. Patient satisfaction was high. The mobility of the operated thumb was restored to a range of motion comparable to the contralateral thumb. Key pinch and grip strength improved by 13% and 31%, respectively. Overall function, according to Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, improved by 59%. Pain decreased by 85% according to the numerical rating scale. Radiological evaluation revealed no loosening of the implant after 5 years except in one patient who required revision due to polythene wear with secondary joint instability. Another patient had asymptomatic polythene wear that required no revision but remains in follow-up. The 5 year overall survival of the prosthesis was 95%. These medium-term results suggest that the Ivory arthroplasty is a reliable option for treating advanced trapeziometacarpal arthritis, because it appears to give a very good functional outcome and has the potential for long-term survival rates.

Glenohumeral relationship in the transverse plane of the body

Reconstruction of a normal glenohumeral relationship is desirable for a successful arthroplasty. Double-contrast computed tomography was performed on 49 healthy shoulders in young volunteers. For creation of a uniform spatial reference system, the subjects were positioned in a thoracobrachial orthosis with the arm adducted in the coronal plane and the forearm flexed in the sagittal plane, and they were examined in dorsal recumbency. The classical anatomic angles were measured, and the anatomic axes were determined and quantified as angles to the coronal plane. When the axis of the glenoid was correlated to the axis of the humeral head, a mean of 8.5 degrees divergence in a clear Gaussian distribution was found. This contrasts with the variability of the version of the humeral head and of the glenoid and offers a useful guideline in difficult prosthetic surgery of the shoulder in which normal anatomic landmarks are lost because of arthritic or traumatic deformity.

Reversed arthroscopic subacromial decompression for symptomatic irreparable rotator cuff tears: mid-term follow-up results in 34 shoulders

BACKGROUND

In the elderly, there is no guideline for the treatment of irreparable rotator cuff lesions. The results of open or arthroscopic repair are variable. We hypothesized that the use of a reversed arthroscopic subacromial decompression (RASD) would yield comparable results.

MATERIAL AND METHODS

Between January 2004 and December 2006, thirty-eight patients underwent a RASD for irreparable cuff tears in 39 shoulders. The surgical procedure consisted of a tenotomy of the long head of the biceps tendon, a debridement of the torn rotator cuff and a tuberoplasty, without violation of the coracoacromial arch and the acromion.

RESULTS

Thirty-three patients (age 69.9 +/- 7.3 years) were available for clinical and radiological evaluation of 34 shoulders (male/female ratio: 11/22), at a mean follow-up of 38 months (range: 21 months-52 months). Two of 33 patients had required revision surgery, and were excluded from further statistical analysis. In the remaining 31 patients (32 shoulders), the modified Constant-Murley score (CMS) improved from 34.9% +/- 11.6 to 84.0% +/- 11.6 (p < 0.0001). The preoperative mobility did not correlate with the final result. Preoperative pain was found to correlate negatively to the modified CMS at follow-up (p= 0.0038). Although the acromiohumeral height decreased with 2.58 mm +/- 1.68 and the severity of glenohumeral osteoarthritis increased with one grade (Samilson-Prieto classification), there was no correlation with the functional outcome.

CONCLUSION

We conclude that for irreparable rotator cuff tears in the elderly, excellent mid-term results can be achieved with a RASD.

De Quervain Tenosynovitis Following Trapeziometacarpal Ball-and-Socket Joint Replacement

Background One of the surgical treatment options for trapeziometacarpal (TMC) joint arthritis is a prosthetic ball-and-socket replacement. One of the complications in the postoperative setting is de Quervain tendinopathy. Purposes Although this complication has been reported following a resection athroplasty, we questioned whether lengthening of the thumb following the Ivory (Memometal, Stryker Corporate, Kalamazoo, MI, USA) ball-and-socket arthroplasty could be a causal factor. Methods In a prospective study regarding the overall outcome of the Ivory prosthesis, we analyzed 96 cases (83 patients; 69 female, 12 male, 8 bilateral) of primary implanted Ivory prosthesis and the incidence of de Quervain disease during the first year following surgery. We found a particularly high incidence (17%) of de Quervain tendinopathy the first year following this ball-and-socket arthroplasty. We measured the lengthening of the thumb radiographically in the group presenting de Quervain and the asymptomatic group and compared this measure between the two groups. Results We did not find any measurable or statistically significant difference between the groups regarding lengthening. Discussion These findings suggest that lengthening of the thumb following ball-and-socket arthroplasty is not a causal factor in the development of de Quervain tendinopathy within one year after surgery.

The wrist hyperflexion and abduction of the thumb (WHAT) test: a more specific and sensitive test to diagnose de Quervain tenosynovitis than the Eichhoff's Test

De Quervain's disease has different clinical features. Different tests have been described in the past, the most popular test being the Eichhoff's test, often wrongly named as the Finkelstein's test. Over the years, a misinterpretation has occurred between these two tests, the latter being confused with the first. To compare the Eichhoff's test with a new test, the wrist hyperflexion and abduction of the thumb test, we set up a prospective study over a period of three years for a cohort of 100 patients (88 women, 12 men) presenting spontaneous pain over the radial side of the styloid of the radius (de Quervain tendinopathy). The purpose of the study was to compare the accuracy of the Eichhoff's test and wrist hyperflexion and abduction of the thumb test to diagnose correctly de Quervain's disease by comparing clinical findings using those tests with the results on ultrasound. The wrist hyperflexion and abduction of the thumb test revealed greater sensitivity (0.99) and an improved specificity (0.29) together with a slightly better positive predictive value (0.95) and an improved negative predictive value (0.67). Moreover, the study showed us that the wrist hyperflexion and abduction of the thumb test is very valuable in diagnosing dynamic instability after successful decompression of the first extensor compartment. Our results support that the wrist hyperflexion and abduction of the thumb test is a more precise tool for the diagnosis of de Quervain's disease than the Eichhoff's test and thus could be adopted to guide clinical diagnosis in the early stages of de Quervain's tendinopathy.

Treatment of severe glenoid deficiencies in reverse shoulder arthroplasty: the Glenius Glenoid Reconstruction System experience

BACKGROUND

The treatment of glenoid bone deficiencies in primary or revision total shoulder arthroplasty is challenging. This retrospective study evaluated the short-term clinical and radiologic results of a new custom-made patient-specific glenoid implant.

METHODS

We treated 10 patients with severe glenoid deficiencies with the Glenius Glenoid Reconstruction System (Materialise NV, Leuven, Belgium). Outcome data included a patient-derived Constant-Murley score, a visual analog score (VAS), a satisfaction score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Simple Shoulder Test. We compared the postoperative position of the implant with the preoperative planned position on computed tomography scans.

RESULTS

At an average follow-up period of 30.5 months, the mean patient-derived Constant-Murley score was 41.3 ± 17.5 points (range, 18-76 points) with a visual analog scale of 3.3 ± 2.5 points (range, 0-7 points). The mean 11-item version of the Disabilities of the Arm, Shoulder and Hand score was 35.8 ± 18.4 (range, 2-71), and the mean Simple Shoulder Test was 47.5% ± 25.3% (range, 8%-92%). Eight patients reported the result as better (n = 3) or much better (n = 5). One patient had an elongation of the brachial plexus, and 1 patient had a period of instability. The average preoperative glenoid defect size was 9 ± 4 cm³ (range, 1-14 cm³). The mean deviation between the preoperative planned and the postoperative version and inclination was 6° ± 4° (range 1°-16°) and 4° ± 4° (range 0°-11°), respectively.

CONCLUSION

Early results of the Glenius Glenoid Reconstruction System are encouraging. Adequate pain relief, a reasonable functionality, and good patient satisfaction can be obtained in these difficult cases. Further follow-up will determine the bony ingrowth and subsequent longevity of this patient-specific glenoid component.

Subscapularis release in shoulder replacement determines structural muscular changes

BACKGROUND

Osteotomy of the lesser tuberosity in shoulder arthroplasty allows bony healing of the subscapularis tendon but does not prevent fatty degeneration in its muscle. Occurrence or increase in fatty degeneration may depend on the surgical technique.

QUESTIONS/PURPOSES

We (1) assessed fatty degeneration in the subscapularis muscle and its cross-sectional area after a C-block osteotomy of the lesser tuberosity with minimal mobilization of the subscapularis muscle, and (2) determined whether this technique had any adverse effect on function, fatty degeneration, and cross-sectional area of the subscapularis muscle.

METHODS

We retrospectively examined 36 patients with shoulder replacements who had C-block osteotomies. Constant-Murley scores and clinical signs of subscapularis insufficiency were recorded. We radiographically assessed prosthetic placement. On CT scans, lesser tuberosity healing, fatty degeneration, and cross-sectional area of the subscapularis muscle were determined. The minimum followup was 13 months (mean, 18 months; range, 13-33 months).

RESULTS

The mean absolute Constant-Murley score was 71.2. Two patients had weakness of the subscapularis muscle without loss of active motion. All tuberosities healed anatomically. A normal glenohumeral relationship was found in all cases. Fatty degeneration was Grade 0 in 44%, Grade 1 in 39%, Grade 2 in 14%, and Grade 3 in 3%. The subscapularis muscular cross-sectional area decreased from 16.7 cm(2) preoperatively to 14.5 cm(2) postoperatively (13%).

CONCLUSIONS

The C-block osteotomy with minimal dissection of the subscapularis is associated with a low incidence of fatty degeneration in the subscapularis muscle after shoulder arthroplasty although the muscular cross-sectional area of the subscapularis decreased.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Quantified measurement of subacromial impingement

We modified the Hawkins impingement maneuver in order to develop a quantifiable and reproducible impingement test. The involved anatomic structures were examined with magnetic resonance imaging of 3 cadaveric shoulders. The reproducibility of the clinical sign was assessed with an interobserver and intraobserver reliability test, with calculation of the intraclass correlation coefficient (ICC). The quantified Hawkins maneuver appears to be a reproducible clinical test (median interobserver ICC, 0.9331; median intraobserver ICC, 0.9748) and creates bony contact between the greater tuberosity and the anterolateral acromion. This test enables the clinician to quantify the subacromial space.

A new prosthetic design for proximal humeral fractures: reconstructing the glenohumeral unit

A new shoulder prosthesis design for proximal humeral fractures has been developed. The rim of the articular component of this prosthesis has several holes to which the bone-tendon junction of the rotator cuff is fixed, to allow an anatomic reconstruction of the glenohumeral unit. The strength of the tuberosity fixation to this prosthesis is investigated in a cadaveric study. Artificial 4-part fractures were created in 18 human, fresh-frozen, paired shoulder joints with intact rotator cuffs. Two methods of tuberosity fixation were used in a matched-pair fashion. In group I the tuberosities were sutured to the rim of the prosthetic head, and in group II the tuberosities were circumferentially tension band-wired. Strength testing was performed on a material-testing machine, and displacement was recorded with an opto-electronic device. Both fixation methods proved to be equally reliable in the forces exerted during activities of daily living without significant displacement of the fracture fragments.

Addition-subtraction osteotomy with ligamentoplasty for symptomatic trapezial dysplasia with metacarpal instability

Trapeziometacarpal instability with trapezial dysplasia is a disabling condition long before the radiological changes of osteoarthritis appear. In dysplastic joints surgical soft tissue correction fails to prevent the instability, requiring a correction of the bony anatomy. We combined two techniques described in the past, an abduction osteotomy of the first metacarpal and an opening wedge osteotomy of the trapezium, to which we added a ligament reconstruction. The combination of both osteotomy techniques restores the anatomy and centres the forces acting across the joint. We have done this procedure 21 times since 2003 in 18 patients. Seventeen thumbs were reviewed prospectively with a mean follow-up of 39 (range 16-65) months. Mean QuickDASH improved by 33.9 points, the key pinch improved by 1.8 kg and the grip strength improved by 8.7 kg. The visual analogue scale for pain improved from 7.9 preoperatively to 2 postoperatively. This technique preserves the trapeziometacarpal joint, allowing other techniques to be used if painful arthritis should develop in the middle to long term.

Pulley Reconstruction As Part of the Surgical Treatment for de Quervain Disease: Surgical Technique with Medium-Term Results

Background Simple decompression of the first extensor compartment is commonly used for treating de Quervain disease, with the possible complication of subluxation of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) over the radial styloid. To prevent this painful subluxation of the tendons, several methods of reconstructing the pulley have been proposed. Questions/Purposes The purpose of our study was to evaluate a new technique for reconstructing the first extensor compartment following a release for de Quervain disease. Patients and Methods A retrospective study (mean length 40.4 months) was performed in 45 patients. The outcome assessment involved two different questionnaires and ultrasound evaluation of any tendon subluxation. Results None of the patients required reoperation for tendon instability or incomplete decompression of the first extensor compartment. Two patients experienced clicking around the radial styloid after surgery. This was not related to the amount of volar migration of the tendons. Conclusions We believe the reconstruction proposed here is an effective method of preventing painful subluxation of the APL and EPB following a release of the first extensor compartment.

Traitement des dysplasies trapéziennes symptomatiques instables par ostéotomie d'addition–soustraction et ligamentoplastie

INTRODUCTION

Trapezometacarpal instability with trapezial dysplasia is an incapacitating condition long before radiological changes appear. Most of the patients are young and demanding. Treatment is often conservative. Surgical treatment options are relatively classic, starting with a ligamentoplasty of the base of the first metacarpal or a tenotomy of the transarticular accessory slip of the abductor pollicis longus. Other options such as arthrodesis and arthroplasty have not been so successful in this situation.

METHOD

The idea arose to combine two techniques described previously. In 1973 Wilson published his technique of abduction osteotomy of the first metacarpal as a treatment for basal osteoarthritis of the thumb. In 2002, Kapandji and Heim published their opening wedge osteotomy of the trapezium in order to correct the slope of a dysplastic trapezium. The combination of both of these techniques avoids closing of the first web by utilising the abduction osteotomy of the first metacarpal. Moreover, the opening wedge osteotomy corrects the dysplastic lateral rim of the trapezium by correcting its slope.

RESULTS

We have been performing this technique since 2001 and 2005 in six patients. The preliminary results are encouraging, 5 of them were able to resume their work. A fair result was achieved in a young patient.

DISCUSSION

The described technique is relatively easy and has the advantage of preserving the trapezometacarpal joint. In addition, it leaves the door open for other techniques if it eventually should fail in the long term.

Epidermoid cyst of the phalanx of the finger caused by nail biting

Intraosseous epidermoid inclusion cysts of the phalanx of the finger are rare, and are regarded as reactive or post-traumatic pseudotumours. We describe a case of an epidermoid cyst in the distal phalanx of the fifth finger caused by chronic nail biting, which was successfully excised.

The Oblique Metaphyseal Shortening Osteotomy of the Distal Ulna: Surgical Technique and Results of Ten Patients

Background Ulnocarpal abutment is a common condition following distal radius fractures. There are different surgical methods of treatment for this pathology: open and arthroscopic wafer procedure or an ulnar shortening osteotomy. We describe an oblique metaphyseal shortening osteotomy of the distal ulna using two cannulated headless compression screws. We report the results of 10 patients treated with this method. Materials and Methods Out of 17 patients, 10 could be reviewed retrospectively for this study. Patient-rated outcomes were measured using the VAS (visual analogue scale) for pain, PRWHE (patient-rated wrist and hand evaluation) survey, and Quick-DASH (disability of arm, shoulder and hand) survey for functional outcomes. At the review we measured the range of motion (ROM) of the wrist (extension and flexion, ulnar and radial deviation, pronation and supination). Grip strength, pronation, and supination strength of the forearm was measured using a calibrated hydraulic dynamometer. ROM and strength of the affected wrist was compared with ROM and strength of the unaffected wrist. Surgical Procedure Oblique long metaphyseal osteotomy of the distal ulna (from proximal-ulnar to distal-radial), fixed with two cannulated headless compression screws. Results The average postoperative VAS score for pain was 23.71 (standard deviation [SD] of 30.41). The average postoperative PRWHE score was 32.55 (SD of 26.28). The average postoperative Quick-DASH score was 28.65 (SD of 27.21). The majority of patients had a comparable ROM and strength between the operated side and the non-operated side. Conclusion This surgical technique has the advantage of reducing the amount of hardware and to decrease the potential hinder caused by it on medium term. Moreover, the incision remains smaller, and the anatomic metaphyseal localization of the osteotomy potentially allows a better and rapid healing.

Three-dimensional analysis of the orientation and the inclination of the rotator cuff footprint

HYPOTHESIS

The tuberosities of the proximal humerus relate geometrically to the humeral head in an anteroposterior symmetry.

MATERIAL AND METHODS

Twenty-eight cadaveric shoulders were scanned with computed tomography and reconstructed digitally in 3 dimensions. On both tuberosities, 5 facets were identified. An orthogonal planar system using the center of the humeral head as its origin was created to calculate the coordinates of the centre of each facet. The angular position of the center of each facet was measured with reference to the sagittal plane. The inclination of each facet was measured to the axial plane.

RESULTS

The presence of 5 distinct facets with a different inclination was confirmed (lesser tuberosity: inferior facet: 77.8° [sd 7.8°]; superior facet: 50.3° [sd 9.3°] - greater tuberosity: superior facet: 20.4° (sd 5.6°); middle facet: 48.6° (sd 5.2°); inferior facet: 92.7° [sd 7.7°]). The angular position of the centers of the facets was less variable (lesser tuberosity: inferior facet: 22.6° [sd 4.3°]; superior facet: 39.2° [sd 4.4°] - greater tuberosity: superior facet: 89.9° [sd 5.9°]; middle facet: 131.6° [sd 6.1°]; inferior facet: 155.1° [sd 6.8°]).

CONCLUSION

Our study contributes to the knowledge of the anatomy of the proximal humerus, more specifically of the position of the rotator cuff insertion in relation to the humeral head. These insights are useful in the development of shoulder trauma prostheses.

Pulley Reconstruction for Symptomatic Instability of the Tendons of the First Extensor Compartment Following de Quervain's Release

Background  Surgical management of de Quervain's tenosynovitis is based on decompression of the first extensor compartment. A simple release of the first compartment can cause instability of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons in zone seven of the extensors. The WHAT test (wrist hyperflexion and abduction of the thumb) is very effective in diagnosing this instability. Patients and Methods  In this retrospective monocentric study, we analyzed a case series of 10 patients all of whom underwent a reconstruction of the first extensor compartment using a retinacular graft because of symptomatic instability after decompression surgery. The reconstruction was a modified technique of the sixth compartment. Functional outcome and characteristics of the newly reconstructed pulley were examined by physical examination with the aid of ultrasound and internationally validated questionnaires. Results  Four patients had a good-to-excellent functional outcome, all of those had a maximum of two surgical procedures performed on the first extensor compartment. Six patients presented poor functional outcome. In four of them, more than two surgical procedures were performed. Minor residual instability was noted in six cases, found in both the groups. Conclusion  The reconstruction procedures on the first compartment seemed to be satisfactory in treating instability of the EPB and APL tendons after primary surgical release for de Quervain's disease. Level of Evidence  Level IV, observational study without controls.

Diagnostic value of active protraction and retraction for sternoclavicular joint pain

Background

Sternoclavicular joint (SCJ) arthropathy is an uncommon cause of mechanical pain. The aim of this study is to evaluate the diagnostic value of two active clinical tests for localizing the sternoclavicular joint as the source of mechanical pain.

Methods

All patients between June 2011 and October 2013 that visited the orthopedic departments of three hospitals with atraumatic pain in the area of the SC joint were evaluated. Local swelling, pain at palpation, pain during arm elevation and two newly described tests (pain during active scapular protraction and retraction) were evaluated. CT images were evaluated. The patients were then divided into two groups according to whether they had a ≥50% decrease in pain following the SCJ injection. Sensitivity and specificity for local swelling, the four clinical tests and CT-scan were measured.

Results

Forty eight patients were included in this study and SC joint pain was confirmed in 44. The tests with highest sensitivity were pain on palpation, (93% sensitivity) and pain during active scapular protraction (86%). CT-scan showed a sensitivity of 84%. Local swelling showed a high specificity (100%).

Conclusion

Pain at the SCJ during active scapular protraction is a good clinical diagnostic tool for SC arthropathy.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-421) contains supplementary material, which is available to authorized users.

Can an extracorporeal glenoid aiming device be used to optimize the position of the glenoid component in total shoulder arthroplasty?

PURPOSE

Successful total shoulder arthroplasty (TSA) requires a correct position of the glenoid component. This study compares the accuracy of the positioning with a new developed glenoid aiming device and virtual three-dimensional computed tomography (3D-CT) scan positioning.

MATERIALS AND METHODS

On 39 scapulas from cadavers, a K-wire (KDev) was positioned using the glenoid aiming device. It consists of glenoid components connected to the aiming device, which cover 150° of the inferior glenoid circle, has a fixed version and inclination and is available with several different radii. The aiming device is stabilized at the most medial scapular point. The K-wire is drilled from the center of the glenoid component to this most medial point. All scapulas were also scanned with CT and 3D reconstructed. A virtual K-wire (Kct) was positioned in the center of the glenoid and in the scapular plane. Several parameters were compared. Radius of the chosen glenoid component (rDev) and the virtual radius of the glenoid circle (rCT), spinal scapular length with the device (SSLdev) and virtual (SSLct), version and inclination between KDev and Kct, difference between entry point and exit point ("Matsen"-point).

RESULTS

Mean rDev: 14 mm ± 1.7 mm and mean rCT: 13.5 mm ± 1.6 mm. There was no significant difference between SSLdev (110.6 mm ± 7.5 mm) and SSLct (108 mm ± 7.5 mm). The version of KDev and Kct was -2.53° and -2.17° and the inclination 111.29° and 111.66°, respectively. The distance between the "Matsen-point" device and CT was 1.8 mm.

CONCLUSION

This glenoid aiming device can position the K-wire on the glenoid with great accuracy and can, therefore, be helpful to position the glenoid component in TSA. The level of evidence: II.