Three-dimensional evaluation of the transverse rotator cuff muscle's resultant force angle in relation to scapulohumeral subluxation and glenoid vault morphology in nonpathological shoulders

BACKGROUND

Static posterior subluxation of the humeral head (SPSH) results in glenohumeral osteoarthritis. Treatment strategies for SPSH with or without resulting osteoarthritis remain challenging. There is growing interest in evaluating the rotator cuff muscle volume, fatty infiltration, or forces in osteoarthritic shoulders with SPSH, mainly due to a possible transverse force imbalance. In nonpathological shoulders, the transverse angle of the rotator cuff muscle's resultant force may be associated with scapulohumeral alignment and glenoid vault morphology, despite an assumed transverse force balance. The purpose of this study was to assess the transverse rotator cuff muscle's resultant force angle (TRFA) and its relationship with the scapulohumeral subluxation index (SHSI) and selected glenoid vault parameters using computer modeling.

METHODS

Computed tomography scans of 55 trauma patients (age 31 ± 13 years, 36 males) with nonpathological shoulders were analyzed and all measurements performed in 3-dimension. We placed landmarks manually to determine the humeral head center and the rotator cuff tendon footprints. The contours of the rotator cuff muscle cross-sectional areas were automatically predicted in a plane perpendicular to the scapula. Each rotator cuff muscle was divided into virtual vector fibers with homogeneous density. The resultant force vector direction for each muscle, corresponding to the rotator cuff action line, was calculated by vectorially summing the normalized fiber vectors for each muscle, weighted by the muscle trophic ratio. The resultant force vector was projected on the axial plane, and its angle with the mediolateral scapular axis was used to determine TRFA. The SHSI according to Walch, glenoid version angle (GVA), glenoid anteroposterior offset angle (GOA), glenoid depth, glenoid width, and glenoid radius were also evaluated.

RESULTS

The mean values for TRFA, SHSI, GVA, GOA, glenoid depth, glenoid width, and glenoid radius were 7.4 ± 4.5°, 54.3 ± 4.8%, -4.1 ± 4.4°, 5.1 ± 10.8°, 3.3 ± 0.6 mm, 20 ± 2 mm, and 33.6 ± 4.6 mm, respectively. The TRFA correlated strongly with SHSI (R = 0.731, P < .001) and GVA (R = 0.716, P < .001) and moderately with GOA (R = 0.663, P < .001). The SHSI was strongly negatively correlated with GVA (R = -0.813, P < .001) and moderately with GOA (R = -0.552, P < .001). The GVA correlated strongly with GOA (R = 0.768, P < .001). In contrast, TRFA, SHSI, GVA, and GOA did not correlate with glenoid depth, width, or radius.

CONCLUSION

Despite an assumed balance in the transverse volume of the rotator cuff muscles in nonpathological shoulders, variations exist regarding the transverse resultant force depending on the SHSI, GVA, and GOA. In healthy/nonosteoarthritic shoulders, an increased glenoid retroversion is associated with a decreased anterior glenoid offset.

Flexed elbow, abducted shoulder, forearm supinated (FABS) reconstruction from three-dimensional elbow MRI: diagnostic performance assessment in biceps head anatomy and pathology

AIM

To determine inter-reader analysis and diagnostic performance on digitally reconstructed virtual flexed, abducted, supinated (FABS) imaging from three-dimensional (3D) isotropic elbow magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Six musculoskeletal radiologists independently evaluated elbow MRI images with virtual FABS reconstructions, blinded to clinical findings and final diagnoses. Each radiologist recorded a binary result as to whether the tendon was intact and if both heads were visible, along with a categorical value to the type of tear and extent of retraction in centimetres where applicable. Kappa and interclass correlation (ICC) were reported with 95% confidence intervals. Areas under the receiver operating curve (AUC) were reported.

RESULTS

FABS reconstructions were obtained successfully in all 48 cases. With respect to tendon intactness, visibility of both heads, and type of tear, the Kappa values were 0.66 (0.53-0.78), 0.24 (0.12-0.37), and 0.55 (0.43-0.66), respectively. For the extent of retraction, the ICC was 0.85 (0.79-0.91) when including the tendons with and without retraction and 0.78 (0.61-0.91) when only including tendons with retraction. For tear versus no tear, AUC values were 0.82 (0.74-0.89) to 0.96 (0.91-1.01).

CONCLUSION

Digital reconstruction of FABS positioning is feasible and allows good assessment of individual tendon head tears and retraction with high diagnostic performance.

Biomechanical comparison of open Bankart repair vs. conjoint tendon transfer in a 10% anterior glenoid bone loss shoulder instability model

BACKGROUND

The treatment of shoulder instability in patients with subcritical glenoid bone loss poses a difficult problem for surgeons as new evidence supports a higher failure rate when a standard arthroscopic Bankart repair is used. The purpose of this study was to compare a conjoint tendon transfer (soft-tissue Bristow) to an open Bankart repair in a cadaveric instability model of 10% glenoid bone loss.

METHODS

Eight cadaveric shoulders were tested using a custom testing system that allows for a 6-degree-of-freedom positioning of the glenohumeral joint. The rotator cuff muscles were loaded to simulate physiologic muscle conditions. Four conditions were tested: (1) intact, (2) Bankart lesion with 10% bone loss, (3) conjoint tendon transfer, and (4) open Bankart repair. Range of motion, glenohumeral kinematics, and anterior-inferior translation at 60° of external rotation with 20 N, 30 N, and 40 N were measured in the scapular and coronal planes. Glenohumeral joint translational stiffness was calculated as the linear fit of the translational force-displacement curve. Force to anterior-inferior dislocation was also measured in the coronal plane. Repeated measures analysis of variance with a Bonferroni correction was used for statistical analysis.

RESULTS

A Bankart lesion with 10% bone loss increased the range of motion in both the scapular (P = .001) and coronal planes (P = .001). The conjoint tendon transfer had a minimal effect on the range of motion (vs. intact P = .019, .002), but the Bankart repair decreased the range of motion to intact (P = .9, .4). There was a significant decrease in glenohumeral joint translational stiffness for the Bankart lesion compared with intact in the coronal plane (P = .021). The conjoint tendon transfer significantly increased stiffness in the scapular plane (P = .034), and the Bankart repair increased stiffness in the coronal plane (P = .037) compared with the Bankart lesion. The conjoint tendon transfer shifted the humeral head posteriorly at 60° and 90° of external rotation in the scapular plane. The Bankart repair shifted the head posteriorly in maximum external rotation in the coronal plane. There was no significant difference in force to dislocation between the Bankart repair (75.8 ± 6.6 N) and the conjoint tendon transfer (66.5 ± 4.4 N) (P = .151).

CONCLUSION

In the setting of subcritical bone loss, both the open Bankart repair and conjoint tendon transfer are biomechanically viable options for the treatment of anterior shoulder instability; further studies are needed to extrapolate these data to the clinical setting.

Combined repair of scapholunate ligament (SL) and triangular fibrocartilage complex (TFCC) lesions in chronic trauma of the wrist: surgical treatment of 14 patients

PURPOSE

Injuries of the scapholunate ligament (SL) and of the triangular fibrocartilage complex (TFCC) represent the main ligament injuries of the traumatic wrist. A double injury of the SL and TFCC ligaments is quite common in the trauma setting, and clinical examination is fundamental. MRI allows to detection of a TFCC and SL ligament injury, but wrist arthroscopy is still the gold standard for diagnosis. We present the clinical results of the combined reconstruction of chronic scapholunate ligament and TFCC injury.

MATERIALS AND METHODS

Fourteen patients were treated at our hospital with a combined scapholunate ligament and TFCC complex repair. All patients were surgically treated by the same senior author, after a diagnostic arthroscopy that revealed a lesion of both structures. A comparison between the pre-operative and post-operative pain and function was carried out using VAS, Disability of Arm, Shoulder and Hand score (DASH) and Patient-Related Wrist/Hand Evaluation score (PRWHE). Wrist range of motion and strength were also compared following surgery.

RESULTS

All patients had a mean follow-up of 54 months. A statistically significant improvement was observed both with the reduction in pain (VAS from 8.9 to 5) and with the improvement of functionality scores (DASH from 63 to 40 and PRWHE from 70 to 57) and with the increase in ROM and strength. In only one patient (7%), because of pain and instability, a supplement operation was needed (Sauve-Kapandji procedure) 3 months after the initial surgery.

CONCLUSIONS

The simultaneous repair of the SL and TFCC complex has shown a good success rate in both decreasing pain and regaining functionality.

Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis

» The proximal humerus is a common location for primary bone tumors, and the goal of surgical care is to obtain a negative margin resection and subsequent reconstruction of the proximal humerus to allow for shoulder function.» The current evidence supports the use of reverse total shoulder arthroplasty over hemiarthroplasty when reconstructing the proximal humerus after resection of a bone sarcoma if the axillary nerve can be preserved.» There is a lack of high-quality data comparing allograft prosthetic composite (APC) with endoprosthetic reconstruction of the proximal humerus.» Reverse APC should be performed using an allograft with donor rotator cuff to allow for soft-tissue repair of the donor and host rotator cuff, leading to improvements in shoulder motion compared with an endoprosthesis.

Advances in Oncologic Shoulder Girdle Resection and Reconstruction

The bony shoulder girdle consists of the clavicle, humerus, and scapula, which work synergistically to form a complex articulation that is essential for use of the upper extremity. The shoulder girdle is the most common location for primary and secondary bone tumors in the upper extremity, and following resection of these tumors, reconstruction of the upper extremity is challenging. Compared with those in the lower extremity, reconstructive techniques in the upper extremity have historically been unreliable and fraught with complications and poor functional outcomes. Newer reconstructive techniques using reverse total shoulder arthroplasty and functional muscle flaps have shown promise to improve outcomes while reducing complications for proximal humerus reconstructions. Despite these advancements, reconstruction following scapulectomy remains challenging and is still associated with more frequent complications and compromised function.

How does dynamic arthroscopic tracking compare with radiologic glenoid track for identification of on- and off-track lesions in anterior shoulder instability?

BACKGROUND

Current treatment paradigms for anterior shoulder instability are based on radiologic measurements of glenohumeral bone defects, and mathematical calculation of the glenoid track (GT) is used to classify lesions into on-track and off-track morphology. However, radiologic measurements have shown high variability, and GT widths under dynamic conditions have been reported to be significantly smaller than those under static radiologic conditions. The purpose of this study was to assess the reliability, reproducibility, and diagnostic validity of dynamic arthroscopic standardized tracking (DAST) in comparison to the gold-standard radiologic track measurement method for the identification of on- and off-track bony lesions in patients with anteroinferior shoulder instability.

METHODS

Between January 2018 and August 2022, 114 patients with traumatic anterior shoulder instability were evaluated using 3-T magnetic resonance imaging or computed tomography scans; glenoid bone loss, Hill-Sachs interval, GT, and Hill-Sachs occupancy ratio (HSO) were measured, and defects were classified as on-track or off-track defects and peripheral-track defects (based on HSO percentage) by 2 independent researchers. During arthroscopy, a standardized method (DAST method) was used by 2 independent observers to classify defects into on-track defects (central and peripheral) and off-track defects. Interobserver reliability of the DAST and radiologic methods was calculated using the κ statistic and reported as percentage agreement. Diagnostic validity (sensitivity, specificity, positive predictive value, and negative predictive value) of the DAST method was calculated using the radiologic track (HSO percentage) as the gold standard.

RESULTS

The radiologically measured mean glenoid bone loss percentage, Hill-Sachs interval, and HSO in off-track lesions were lower with the arthroscopic method (DAST) as compared with the radiologic method. The DAST method showed nearly perfect agreement between the 2 observers for the on-track/off-track classification (κ = 0.96, P < .001) and the on-track central or peripheral /off-track classification (κ = 0.88, P < .001). The radiologic method showed greater interobserver variability (κ = 0.31 and κ = 0.24, respectively) with only fair agreement for both classifications. Inter-method agreement varied between 71% and 79% (95% confidence interval, 62%-86%) between the 2 observers, and reliability was assessed as slight (κ = 0.16) to fair (κ = 0.38). Overall, for identification of an off-track lesion, the DAST method showed maximum specificity (81% and 78%) when radiologic peripheral-track lesions (HSO percentage of 75%-100%) were considered off-track and showed maximum sensitivity when arthroscopic peripheral-track lesions were classified as off-track.

CONCLUSION

Although inter-method agreement was low, a standardized arthroscopic tracking method (DAST method) showed superior interobserver agreement and reliability for lesion classification in comparison to the radiologic track method. Incorporating DAST into current algorithms may help reduce variability in surgical decision making.

Sporadic Malignant Triton Tumor of Shoulder: a Case Report

Background

Malignant triton tumors (MTT) are subtype of malignant peripheral nerve sheath tumor (MPNST) which develop from Schwan cells of peripheral nerves or within neurofibromas, and shows rhabdomyoblastic differentiation. It is a rare soft tissue tumor with poor prognosis.

Objective

We report a case of Malignant Triton Tumor (MTT) arising in the right shoulder in a 46 year old male patient presented to our Musculoskeletal Oncology Clinic at Royal Rehabilitation center at King Hussein Medical Center during June 2018.

Case presentation

The patient was complaining of an 8 months long progressive right shoulder pain and swelling at the posterior lateral area of the shoulder. As accurate diagnosis is crucial in such case, investigations that included x-rays and magnetic resonance imaging (MRI) demonstrated an soft tissue tumor involving the right shoulder area leading to the differential diagnosis of aggressive soft tissue tumor which laid down the plan of an open incisional biopsy to be reported histopathological as a case of Malignant Triton Tumor which is a very rare and aggressive sarcoma originates from the peripheral nerve sheaths as it is subtype of malignant peripheral nerve sheath tumors after which excision of the entire tumor with safety margin was performed and referred for adjuvant chemotherapy.

Conclusion

The treatment of choice is radical tumor excision with wide margins followed by chemotherapy and /or radiotherapy to improve the 5 years survival rates.

[Limb-sparing resection of axillary soft tissue sarcomas]

OBJECTIVE

For patients with soft tissue sarcoma, surgical resection is a key element of curative therapy. Surgery is performed as a wide resection with microscopically negative margins (R0 resection) and as limb-sparing procedure whenever possible to preserve maximum function.

INDICATIONS

Soft tissue sarcoma, metastases.

CONTRAINDICATIONS

Extensive disease with major neurovascular involvement, placement of biopsy tract necessitates extensive resection, palliative care.

SURGICAL TECHNIQUE

Extended deltopectoral approach. Release of pectoralis major and minor tendons. Vascular and neurologic exploration, identification of the axillary vessels and brachial plexus, placing of loops around major structures. Mobilization of these structures to achieve adequate exposure. Clipping of vessels entering the tumor. Tumor resection, suture marking for histological analysis. Soft tissue reconstruction by transosseous reinsertion of the pectoralis minor to the coracoid process. Drill channel placement, transosseous refixation of the pectoralis major to the humerus.

POSTOPERATIVE MANAGEMENT

Shoulder abduction brace for 6 weeks, passive mobilization for 6-12 weeks followed by active mobilization. Compression sleeve. Oncological follow-up.

RESULTS

Between 2017 and 2022, wide resection was performed in 6 consecutive cases including 4 primary soft tissue sarcomas and 2 metastases. Primary R0 resection was achieved in 100%. Mean follow-up was 22.5 months (3-60 months). There were no local recurrences. Mean active shoulder abduction was 135.0 ± 41.4° (90-180°). Neurological deficits were not observed. Mean subjective shoulder function was 80.0 ± 21.0% (50-100%). The mean Musculoskeletal Tumor Society (MSTS) score was 89.5% (32-100%), indicating good functional outcome in the study cohort.

Native Glenoid Depth and Hill-Sachs Lesion Morphology in Traumatic Anterior Shoulder Instability

BACKGROUND

Although Hill-Sachs lesions (HSLs) are assumed to be influenced by glenoid characteristics in the context of bipolar bone loss, little is known about how glenoid concavity influences HSL morphology.

PURPOSE

To investigate the relationship between the native glenoid depth and HSL morphological characteristics.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Computed tomography images of bilateral shoulders from 151 consecutive patients with traumatic unilateral anterior shoulder instability were retrospectively reviewed. Patients were categorized into flat (<1 mm), moderate (1-2 mm), and deep (>2 mm) groups based on the native glenoid depth measured from the contralateral unaffected shoulder. The HSL morphological characteristics included size (depth, width, length, and volume), location (medial, superior, and inferior extent), and orientation (rim and center angle). The glenoid characteristics included diameter, depth, version, and bone loss. The patient, glenoid, and HSL morphological characteristics were compared among the 3 depth groups. Subsequently, the independent predictors of some critical HSL morphological characteristics were determined using multivariate stepwise regression.

RESULTS

After exclusion of 55 patients, a total of 96 patients were enrolled and classified into the flat group (n = 31), moderate group (n = 35), and deep group (n = 30). Compared with those in the flat group, patients in the deep group were more likely to have dislocation (38.7% vs 93.3%; P = .009) at the primary instability and had a significantly larger number of dislocations (1.1 ± 1.0 vs 2.2 ± 1.8; P = .010); moreover, patients in the deep group had significantly deeper, wider, larger volume, more medialized HSLs and higher incidences of off-track HSLs (all P≤ .025). No significant differences were detected among the 3 groups in HSL length, vertical position, and orientation (all P≥ .064). After adjustment for various radiological and patient factors in the multivariate regression model, native glenoid depth remained the strongest independent predictor for HSL depth (β = 0.346; P < .001), width (β = 0.262; P = .009), volume (β = 0.331; P = .001), and medialization (β = -0.297; P = .003).

CONCLUSION

The current study sheds light on the association between native glenoid depth and the morphology of HSLs in traumatic anterior shoulder instability. Native glenoid depth was independently and positively associated with HSL depth, width, volume, and medialization. Patients with deeper native glenoids were more likely to have off-track HSLs and thus require more attention in the process of diagnosis and treatment.

Efficacy of a Novel Electroconductive Matrix To Treat Muscle Atrophy and Fat Accumulation in Chronic Massive Rotator Cuff Tears of the Shoulder

The high retear rate after a successful repair of the rotator cuff (RC) is a major clinical challenge. Muscle atrophy and fat accumulation of RC muscles over time adversely affect the rate of retear. Since current surgical techniques do not improve muscle degenerative conditions, new treatments are being developed to reduce muscle atrophy and fat accumulation. In the previous study, we have shown the efficacy of aligned electroconductive nanofibrous fabricated by coating poly(3,4-ethylene dioxythiophene): poly(styrenesulfonate) (PEDOT:PSS) nanoparticles onto aligned poly(ε-caprolactone) (PCL) electrospun nanofibers (PEDOT:PSS matrix) to reduce muscle atrophy in acute and subacute models of RC tears (RCTs). In this study, we further evaluated the efficacy of the PEDOT:PSS matrix to reduce muscle atrophy and fat accumulation in a rat model of chronic massive full-thickness RCTs (MRCTs). The matrices were transplanted on the myotendinous junction to the belly of the supraspinatus and infraspinatus muscles at 16 weeks after MRCTs. The biomechanics and histological assessments showed the potential of the PEDOT:PSS matrix to suppress the progression of muscle atrophy, fat accumulation, and fibrosis in both supraspinatus and infraspinatus muscles at 24 and 32 weeks after MRCTs. We also demonstrated that the PEDOT:PSS matrix implantation significantly improved the tendon morphology and tensile properties compared with current surgical techniques.

Does glenoid bone loss accompany posterior shoulder instability with only labral tear? A magnetic resonance imaging-based study

BACKGROUND

The primary aim of this study was to investigate bone loss in the glenoid with magnetic resonance imaging in posterior shoulder instability with only a labral tear.

METHODS

A total of 76 patients operated on because of posterior and anteroposterior shoulder instability only with a labral tear between 2006 and 2019 (n = 40 and n = 36, respectively) were included in this study. The instability type, a presence of an additional superior labrum anteroposterior (SLAP) lesion, the number of dislocations, and the magnetic resonance imaging-based measurements (the glenoid diameter and the bone defect size in the glenoid, the Hill-Sachs lesion [HSL] and the reverse HSL [rHSL] length, the angle and the arc length of HSL and rHSL, and the humerus head diameter and its area) were analyzed.

RESULTS

The size of the anterior glenoid defect, the rHSL measurements (length, angle, and arc length), and the ratio of the anterior glenoid defect size to the glenoid diameter were significantly higher for anteroposterior instability (P < .01) cases. There was no significant difference (P = .49, .64, and .82, respectively) for the presence of an additional SLAP pathology, the glenoid diameter, the posterior glenoid defect, and the ratio of the posterior glenoid defect size to the glenoid diameter in posterior and anteroposterior instability groups. The increased number of dislocations was associated with increased rHSL length and total arc length (P = .04 and .03, respectively). An additional SLAP lesion in posterior shoulder instabilities was not associated with the bone defect size (P = .29).

CONCLUSION

Although the posterior shoulder instability with only a labral tear is likely to cause a bone defect, we have shown that the instability is not expected to be caused by the bone defect. Therefore, this study points out that only soft tissue repair without considering the bone defect could be promising in this patient group.

Clinical and functional outcome after partial or total claviculectomy without reconstruction for oncologic causes

BACKGROUND

To achieve clear margins in rare malignant clavicular neoplasms, claviculectomy may become necessary. This study aimed to review clinical, functional, and oncologic outcomes following partial or total claviculectomy without reconstruction.

METHODS

This study retrospectively included 15 patients from 2 tertiary sarcoma centers (mean age, 42.6 ± 20.3 years; 66.7% male patients). The median length of clinical and oncologic follow-up was 48.0 months (interquartile range [IQR], 24.0-83.5 months). Functional follow-up (Musculoskeletal Tumor Society score and QuickDASH score [short version of the Disabilities of the Arm, Shoulder and Hand questionnaire]) was available in 9 patients at a median of 36.0 months (IQR, 20.0-100.0 months).

RESULTS

Of the 15 patients, 7 underwent total claviculectomy; 5, partial lateral claviculectomy; and 3, partial medial claviculectomy. No postoperative complications emerged. The median Musculoskeletal Tumor Society and QuickDASH scores at latest follow-up amounted to 26.0 points (IQR, 24.0-29.0 points) and 18.0 points (IQR, 11.0-22.0 points), respectively. Notably, scores tended to be lower in patients who underwent total claviculectomy (n = 2) in comparison to partial claviculectomy (n = 7).

CONCLUSION

Satisfactory clinical and functional results can be achieved following partial or total claviculectomy without reconstruction, with a low complication rate and acceptable mid- to long-term function.

Functional outcome and quality of life following resection of the proximal humerus performed for musculoskeletal tumors and reconstruction done by four different methods

INTRODUCTION

The proximal humerus is a frequent site for both primary and secondary bone tumors. Several options are currently available to reconstruct the resected humerus, but there is no consensus regarding optimal reconstruction. The aim of this retrospective study was to compare the functional outcome, complications and patient compliance following four different types of reconstructive techniques.

MATERIAL AND METHODS

The authors performed 90 proximal humerus resections due to primary and secondary bone tumors over the past 21 years. Four different procedures were performed for reconstruction following the resection: fibula autograft transplantation, osteoarticular allograft implantation, modular tumor endoprosthesis (hemiarthroplasty) and reconstruction of the defect with a reverse shoulder prosthesis-allograft composite. A retrospective analysis of the complications and patient's physical status was performed. Functional outcome and life quality was evaluated by using the MSTS and SF-36 scores.

RESULTS

The best range of motion was observed following arthroplasty with a reverse shoulder prosthesis-homograft composite followed by a fibula autograft reconstruction. Revision surgery was required due to major complications most frequently in the osteoarticular allograft group, followed by the reverse shoulder prosthesis-allograft composite group, the autologous fibula transplantation group; the tumor endoprosthesis hemiarthroplasty group had superior results regarding revision surgery (40, 25, 24 and 14% respectively). MSTS was 84% on average for the reverse shoulder prosthesis-allograft composite group, 70% for the autologous fibula group, 67% for the anatomical hemiarthroplasty group and 64% for the osteoartricular allograft group. Using the SF-36 questionnaire for assessment no significant differences were found between the four groups regarding quality of life.

DISCUSSION

Based on the results of our study the best functional performance (range of motion and patient compliance) was achieved in the a reverse prosthesis-allograft combination group-in cases where the axillary nerve could be spared. The use of an osteoarticular allograft resulted in unsatisfying functional results and high complication rates, therefore we do not recommend it as a reconstructive method following resection of the proximal humerus due to either primary or metastatic bone tumors. Young patients who have good life expectancy but a small humerus or intramedullar cavity reconstruction by implantation of a fibula autograft is a good option. For patients with a poor prognosis (i.g. bone metastases) or in cases where the axillary nerve must be sacrificed, hemiarthroplasty using a tumor endoprosthesis was found to have acceptable results with a low complication rate. According to the MSTS and SF-36 functional scoring systems patients compliance was nearly identical following all four types of reconstruction techniques; the underlying cause may be the complexity of the shoulder girdle. However, we recommend the implantation of a reverse shoulder prosthesis-allograft whenever indication is appropriate, as it has been demonstrated to provide excellent functional outcomes, especially in young adults.

Lesion prevalence and patient outcome comparison between primary and recurrent anterior shoulder instability

BACKGROUND

The purpose of this study was to compare lesion prevalence and treatment outcomes in patients with primary and recurrent anterior shoulder instability.

METHODS

Patients who were admitted to the institution with a diagnosis of anterior shoulder instability and who underwent arthroscopic surgery between July 2006 and February 2020 were retrospectively evaluated. Minimum follow-up duration of the patients was 24 months. The recorded data and magnetic resonance imaging (MRI) of the patients were examined. Patients aged ≥40 years, with a history of shoulder region fracture, inflammatory arthritis, a history of epilepsy, multidirectional instability, nontraumatic dislocation, and off-track lesions were excluded from the study. Shoulder lesions were documented and patient outcome evaluation was made with the Oxford Shoulder Score (OSS) and visual analog scale (VAS).

RESULTS

A total of 340 patients were included in the study. The mean age of patients was 25.6 years (±6.49). The recurrent instability group had a significantly higher rate of anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions compared to the primary instability group (40.6% vs. 24.6% respectively) (P = .033). Twenty-five patients (43.9%) had superior labrum anterior and posterior (SLAP) lesions in the primary instability group and 81 patients (28.6%) had SLAP lesions in the recurrent instability group (P = .035). OSS increased for both primary (from 35 [16-44] to 46 [36-48]) (P = .001) and recurrent instability groups (from 33 [6-45] to 47 [19-48]) (P = .001). There was no significant difference between the groups regarding postoperative VAS and OSS scores (P > .05).

CONCLUSIONS

Successful results were obtained in patients younger than 40 years with both primary and recurrent anterior shoulder instability after arthroscopic treatment. ALPSA lesion prevalence was higher whereas SLAP lesion prevalence was lower in patients with recurrent instability. Although the postoperative OSS was comparable between the patient groups, the failure rate was higher in the recurrent instability patients.

Long-term outcome of dogs treated by surgical debridement of proximal humeral osteochondrosis

OBJECTIVE

To evaluate long-term clinical outcomes of dogs surgically treated for proximal humeral osteochondrosis (OC).

STUDY DESIGN

Cross-sectional study.

SAMPLE POPULATION

Twenty dogs (n = 26 shoulders).

METHODS

Dogs treated with surgical debridement of proximal humeral OC lesions >12 months prior were enrolled. Orthopedic examination (including limb circumference and shoulder goniometry), kinetic gait analysis, shoulder radiographs, shoulder computed tomography (CT), and shoulder arthroscopy were performed. All owners completed a dog mobility questionnaire.

RESULTS

Brachial circumference (P = .003) and maximum shoulder extension (P = .013) were decreased and maximum shoulder flexion (P = .008) was increased (ie less flexion) in the OC limb versus the contralateral limb in unilaterally affected dogs. There were no differences in peak vertical force and vertical impulse between affected and unaffected limbs. Dogs demonstrated a 4.4% decrease in load distributed to the operated limb. Osteoarthritis was present in all shoulders treated for OC lesions. The degree of osteoarthritis in OC-affected shoulders was increased compared to the contralateral limb as evaluated on CT (P = .005) and radiography (P = .0001) in unilaterally affected cases. Moderate-to-severe synovitis was seen in all OC-affected joints. Arthroscopically, all lesions were noted to have patchy, incomplete cartilaginous infilling. Median of aggregate Liverpool Osteoarthritis in Dogs (LOAD) scores was 6.

CONCLUSION

All dogs exhibited ipsilateral muscle atrophy and progressive osteoarthritis, with most dogs exhibiting subtle lameness on the subjective gait examination. Despite this, owner-perceived mobility was satisfactory.

CLINICAL SIGNIFICANCE

Progression of joint disease over time should be expected; however, the abnormalities detected on examination appear to be of questionable clinical relevance.

Glenoid Track Assessment at Imaging in Anterior Shoulder Instability: Rationale and Step-by-Step Guide

Anterior shoulder dislocation is the most common form of joint instability in humans, usually resulting in soft-tissue injury to the glenohumeral capsuloligamentous and labral structures. Bipolar bone lesions in the form of fractures of the anterior glenoid rim and posterolateral humeral head are often associated with anterior shoulder dislocation and can be a cause or result of recurrent dislocations. Glenoid track assessment is an evolving concept that incorporates the pathomechanics of anterior shoulder instability into its management. Currently widely endorsed by orthopedic surgeons, this concept has ramifications for prognostication, treatment planning, and outcome assessment of anterior shoulder dislocation. The glenoid track is the contact zone between the humeral head and glenoid during shoulder motion from the neutral position to abduction and external rotation. Two key determinants of on-track or off-track status of a Hill-Sachs lesion (HSL) are the glenoid track width (GTW) and Hill-Sachs interval (HSI). If the GTW is less than the HSI, an HSL is off track. If the GTW is greater than the HSI, an HSL is on track. The authors focus on the rationale behind the glenoid track concept and explain stepwise assessment of the glenoid track at CT or MRI. Off-track to on-track conversion is a primary goal in stabilizing the shoulder with anterior instability. The key role that imaging plays in glenoid track assessment warrants radiologists' recognition of this concept along with its challenges and pitfalls and the production of relevant and actionable radiology reports for orthopedic surgeons-to the ultimate benefit of patients. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Biomechanical Evaluation of Posterior Shoulder Instability With a Clinically Relevant Posterior Glenoid Bone Loss Model

BACKGROUND

Existing biomechanical studies of posterior glenoid bone loss and labral pathology are limited by their use of anterior instability models, which differ in both orientation and morphology and have been performed in only a single, neutral arm position.

PURPOSE

To evaluate the biomechanical effectiveness of a posterior labral repair in the setting of a clinically relevant posterior bone loss model in various at-risk arm positions.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten fresh-frozen cadaveric shoulders were tested in 7 consecutive states using a 6 degrees of freedom robotic arm: (1) native, (2) posterior labral tear (6-9 o'clock), (3) posterior labral repair, (4) mean posterior glenoid bone loss (7%) with labral tear, (5) mean posterior glenoid bone loss with labral repair, (6) large posterior glenoid bone loss (28%) with labral tear, and (7) large posterior glenoid bone loss with labral repair. Bone loss was created using 3-dimensional printed computed tomography model templates. Biomechanical testing consisted of 75 N of posterior-inferior force and 75 N of compression at 60° and 90° of flexion and scaption. Posterior-inferior translation, lateral translation, and peak dislocation force were measured for each condition.

RESULTS

Labral repair significantly increased dislocation force independent of bone loss state between 10.1 and 14.8 N depending on arm position. Dislocation force significantly decreased between no bone loss and small bone loss (11.9-13.5 N), small bone loss and large bone loss (9.4-14.3 N), and no bone loss and large bone loss (21.2-26.5 N). Labral repair significantly decreased posterior-inferior translation compared with labral tear states by a range of 1.0 to 2.3 mm. In the native state, the shoulder was most unstable in 60° of scaption, with 29.9 ± 6.1-mm posterior-inferior translation.

CONCLUSION

Posterior labral repair improved stability of the glenohumeral joint, and even in smaller to medium amounts of posterior glenoid bone loss the glenohumeral stability was maintained with labral repair in this cadaveric model. However, a labral repair with large bone loss could not improve stability to the native state.

CLINICAL RELEVANCE

This study shows that larger amounts of posterior glenoid bone loss (>25%) may require bony augmentation for adequate stability.

Atypical Shoulder Instability Patterns in Adolescents Following Traumatic Anterior Shoulder Dislocation

BACKGROUND

Traumatic anterior shoulder instability is common in the adolescent athlete, and when it is untreated, the recurrence rate is high. Atypical lesions-such as anterior glenoid periosteal sleeve, humeral glenohumeral ligament, and insertional tendon avulsions-may occur within this population, and accurate diagnosis and appropriate lesion management are key to treatment success.

PURPOSE

To evaluate the age, skeletal immaturity, bone loss, and uncommon soft tissue lesions as correlates of posttraumatic anterior shoulder instability lesion patterns in an adolescent population.

STUDY DESIGN

Cross-sectional study, Level of evidence, 3.

METHODS

Consecutive patients ≤18 years of age (160 shoulders) treated within a single institution for traumatic anterior shoulder instability between June 2013 and June 2021 were reviewed. Demographics, injury mechanism, radiographic and magnetic resonance imaging of lesions, the presence of any bone loss, operative findings, and physeal status were recorded. An overall 131 shoulders met the inclusion criteria. Instability lesion type was analyzed categorically by age <15 or ≥15 years; individual age was assessed for correlation with any bone loss present. Atypical lesions-anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, subscapularis avulsion-were assessed for correlations with age, open physeal status, and the presence of any bone loss.

RESULTS

An overall 131 shoulders (mean, 15.3 years; range, 10.5-18.3) were identified for this study: 55 in patients <15 years old and 76 in patients ≥15 years old. Bony injuries such as Bankart and Hill-Sachs lesions were more common in the ≥15-year-old group (P = .044 and P = .024, respectively). Bony Bankart injuries were found at a rate of 18.2% in the <15-year-old group, as compared with 34.2% in the ≥15-year-old group (P < .05). Anterior labral periosteal sleeve avulsions were more common in the <15-year-old group (n = 13 [23.6%] vs n = 8 [10.5%]; P < .044), as were all atypical lesions combined (n = 23 [41.8%] vs n = 13 [17.1%]; P < .0018].

CONCLUSION

In this series of anterior shoulder instability in children and adolescents, instability lesions varied significantly by age. Bone loss was associated with older age at presentation, and atypical lesions were more common in patients <15 years of age. Treatment teams should be aware of less common soft tissue injuries in this young age group and ensure careful review of adequate imaging for proper diagnosis and treatment in these younger patients.

Vitamin C as a Potential Prophylactic Measure Against Frozen Shoulder in an In Vivo Shoulder Contracture Animal Model

BACKGROUND

Frozen shoulder is a common, painful, and movement-restricting condition. Although primary frozen shoulder is idiopathic, secondary frozen shoulder can occur after trauma or surgery. Prophylactic and therapeutic options are often unsatisfactory. Vitamin C (ascorbic acid) is a potent physiological antioxidant and likely inhibits the activation of nuclear factor κB, which plays a decisive role in inflammatory reactions.

HYPOTHESIS

Because of its anti-inflammatory effects, vitamin C may be valuable in the prevention of secondary frozen shoulder.

STUDY DESIGN

Controlled laboratory study.

METHODS

An in vivo shoulder contracture model was conducted by fixation of the right proximal limb of Sprague-Dawley rats. A treatment group (n = 8) receiving vitamin C orally was compared with a control group (n = 9) without vitamin C. The primary outcome was capsular thickness at the shoulder joint measured on magnetic resonance imaging (MRI) examination. Further histological examination was performed but was not statistically analyzed because of variability of the cutting plane through the glenoid.

RESULTS

Vitamin C treatment resulted in less thickening of the axillary fold of the operated shoulder at 2 of the 3 locations measured on MRI compared with untreated controls (insertion to the glenoid, P = .074; insertion to the humerus, P = .006; middle of the axillary recess, P = .008). The observed structural changes in histological examination corroborated the significant changes obtained from the MRI measurements.

CONCLUSION

Prophylactic vitamin C seemed to reduce the thickening of the axillary recess in secondary frozen shoulder in this preclinical study.

CLINICAL RELEVANCE

Vitamin C may be helpful as a noninvasive therapeutic measure to prevent secondary frozen shoulder (eg, within the context of surgery in the shoulder region or immobilization) or to treat primary frozen shoulder at an early stage. Further studies are required to evaluate the effect of this treatment in humans and the necessary dosage in humans.

ABER Position in Direct MR Arthrography of the Shoulder: Useful Adjunct or Waste of Imaging Time?

PURPOSE

The usefulness of direct MR arthrography of the shoulder with additional ABER position (ABER-MRA) has always been discussed. The goals of the following review are to analyze the usefulness of this technique according to the available literature and present recommendations with respect to indications and benefits in diagnostic imaging of shoulder abnormalities in the clinical routine.

METHOD

For this review we assessed the current literature databases of the Cochrane Library, Embase, and PubMed with regard to MRA in the ABER position up to the February 28, 2022. Search terms were "shoulder MRA, ABER", "MRI ABER", "MR ABER", "shoulder, abduction external rotation MRA", "abduction external rotation MRI" and "ABER position". The inclusion criteria were prospective and retrospective studies with surgical and/or arthroscopic correlation within 12 months. Overall, 16 studies with 724 patients fulfilled the inclusion criteria: 10 studies dealing with anterior instabilities, three studies with posterior instabilities and seven studies with suspected rotator cuff pathologies (some studies addressing multiple items).

RESULTS

For anterior instability the use of ABER-MRA in the ABER position led to a significant increase in sensitivity for detecting lesions of the labral ligamentous complex compared with standard 3-plane shoulder MRA (81 % versus 92 %, p = 0.001) while maintaining high specificity (96 %). ABER-MRA demonstrated high sensitivity and specificity (89 % and 100 %, respectively) for SLAP lesions and was able to detect micro-instability in overhead athletes, but case counts are still very small. With regard to rotator cuff tears, no improvement of sensitivity or specificity could be shown with use of ABER-MRA.

CONCLUSION

Based on the currently available literature, ABER-MRA achieves a level of evidence C in the detection of pathologies of the anteroinferior labroligamentous complex. With regard to the evaluation of SLAP lesions and the exact determination of the degree of rotator cuff injury, ABER-MRA can be of additive value, but is still a case-by-case decision.

KEY POINTS

· ABER-MRA is useful in the evaluation of pathologies of the anteroinferior labroligamentous complex. · ABER-MRA does not increase sensitivity or specificity with regard to rotator cuff tears. · ABER-MRA may be helpful for the detection of SLAP lesions and micro-instability in overhead athletes.

CITATION FORMAT

· Altmann S, Jungmann F, Emrich T et al. ABER Position in Direct MR Arthrography of the Shoulder: Useful Adjunct or Waste of Imaging Time?. Fortschr Röntgenstr 2023; 195: 586 - 595.

Rice bodies in a shoulder bursa: a cadaveric and histologic case report

INTRODUCTION

The subacromial/subdeltoid bursa can develop inflammation and effusion related to autoimmune, infectious, and musculoskeletal disorders. Rice bodies, or loose bodies within bursa, have been described as an uncommon complication of bursitis and have been the subject of case studies over a number of years. However, they have not been described in anatomical or physical therapy-related literature.

METHODS

A donor body dissected for a physical therapy anatomy course was found to have an enlarged subacromial/subdeltoid bursa. This bursa, along with the biceps brachii tendon sheath, and the subscapularis muscle bursa, were filled with numerous rice-like bodies. The bursal wall was well developed and thickened. Tissue specimens were obtained of the suspected rice bodies, the subacromial/subdeltoid bursal wall, and the biceps brachii tendon sheath. The tissue was embedded, sectioned, and processed with hematoxylin and eosin or Masson's Trichrome staining for blinded histologic assessment.

RESULTS

The tissue samples from within the bursa were identified as tissue similar to that in prior descriptions of rice bodies. Tissue samples from the bursal wall and tendon sheath were identified as similar to synovial membranes.

CONCLUSIONS

Rice bodies found within the cadaveric body were similar histologically to those described in rheumatology, radiology, and orthopedic literature. Anatomists teaching future health-care providers and practicing physical therapists should be familiar with rice bodies as a potential finding in cadavers, and patients.

Neuropathic arthropathy of the shoulder as a presenting feature of Chiari malformation with syringomyelia: a case report with a systematic literature review

BACKGROUND

Neuropathic arthropathy (NA) of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Syringomyelia, a spinal cord disease, is the leading cause of NA in the upper extremity.

OBJECTIVE

We present a systematic review of NA with syringomyelia cases alongside a case report of an adult with NA of the shoulder that occurs a few 4 years after a revelation and surgical management of a Chiari malformation with syringomyelia.

METHODS

A systematic review was conducted following PRISMA guidelines. A PubMed, Scopus, Isiknowledge, and manual search through references of relevant publications were used to identify all published case reports of NA. Data were collected from each case report on patient characteristics.

RESULTS

The systematic review identified 56 publications and 85 patients (including ours): nearly the same number of males (n = 41) and females (n = 44). The mean age was 50,69. Presentations included reduction of mobility (n = 66), swelling (n = 61) and sensory disorder (n = 63). The pain was absent in 41 cases. In the majority of reported cases 56 (65.1%), syringomyelia was revealed by neuropathic arthropathy, and eleven patients (12.9%) had a history of syringomyelia. Treatment was categorized into non-operative management (37[43.5%]), operative management (27[31.7%]). Following-up was non-reported in 31 (36%) cases. Improvement was reported more with patients who underwent a surgical approach than medical one 28.5% versus 8.1%.

CONCLUSION

Physicians need to be more aware of this destructive joint disease, rare, and often misdiagnosed. Also, it is imperative to integrate clinical, pathological, and imaging findings for accurate diagnosis and for delivering appropriate therapy.

The Double-Circle System in the Greater Tuberosity: Using Radius to Predict Rotator Cuff Tear

OBJECTIVE

In this study we concerned on the morphological characteristics of the greater tuberosity of humerus and proposed the double-circle radius ratio as a new predictor for the diagnosis of rotator cuff tears.

METHODS

This was a retrospective study and patients who visited our hospital and were diagnosed with or without rotator cuff tears via magnetic resonance imaging from January 2018 to July 2021 were enrolled and classified into two groups respectively. In a standard anteroposterior view, the radius of the best-fit circle of humeral head and the radius of the concentric circle passing through the most lateral edge of the greater tuberosity were measured in each shoulder. The ratio of these two radiuses was named as the double-circle radius ratio. Angular parameters including the greater tuberosity angle and the critical shoulder angle were also measured in the anteroposterior view. Independent samples t tests and chi-square tests were used to find significant differences between groups. Significant associations between those measured variables and demographic characteristics were analyzed with simple linear regression analysis. Receiver operating characteristic curves were pictured to determine applied cutoff values by using Youden index. Multivariable-adjusted analysis for the occurrence of rotator cuff tears was carried out by using multiple logistic regression analysis. For all tests a p value of <0.05 was considered statistically significant.

RESULTS

One hundred and twelve shoulders with rotator cuff tears and 42 shoulders without rotator cuff tears were included. The mean value of the double-circle radius ratio was significantly larger in shoulders with rotator cuff tears (1.42 ± 0.09 vs. 1.30 ± 0.07, P = 0.000). With simple linear regression analysis, the radiuses of the humeral head and the greater tuberosity were significantly associated with heights and weights. In receiver operating characteristic curves, the largest area was found under the curve of the double-circle radius ratio as 0.846 (95% CI, 0.781-0.911; P = 0.000) with an applied cutoff value as 1.38 (sensitivity, 70.5%; specificity, 88.1%). Multivariable-adjusted analysis showed that a value of the double-circle radius ratio >1.38 resulted in 11.252-fold odds of developing rotator cuff tears (95% CI, 3.388-37.368; P = 0.000).

CONCLUSION

The double-circle radius ratio is significantly larger in patients with rotator cuff tears and could be regarded as an eligible predictor for rotator cuff tears.

Primitive Neuroectodermal Tumour of Subcutaneous Tissue Presenting as a Shoulder Lump: A Case Report

Primitive neuroectodermal tumour is a poorly differentiated small round cell neoplasm that primarily affects children and is very rarely seen in adults. Peripheral primitive neuroectodermal tumours are rare compared to the central type and resemble soft tissue sarcoma. Primitive neuroectodermal tumours involving the subcutaneous tissue are rare and only a few cases involving the subcutaneous tissue of the anterior abdominal wall have been reported. However, no cases involving the subcutaneous tissue of the shoulder region have been reported. We report the case of a peripheral primitive neuroectodermal tumour arising from subcutaneous tissue of the right shoulder in a young adult.

Synchronous Primary Multifocal Skeletal Chondrosarcoma of Extremity: A Report of 2 Cases

CASE

Multifocal synchronous primary skeletal chondrosarcomas of an extremity are rarely reported. In this study, we report 2 such cases. The first case is a 32-year-old woman who presented with extensive right femoral and tibial diaphysis lesions. The second case is a 36-year-old woman with lesions in the left proximal humerus, the coracoid process of scapula and sternum. Both patients underwent limb salvage surgery and were disease-free at the 38- and 20-month follow-up.

CONCLUSION

Athough rare, the possibility of multifocal chondrosarcoma should be kept in mind during the workup of a patient with chondrosarcoma.

An unusual case of metaphyseal osteonecrosis of humerus in a post covid patient: a case report

Osteonecrosis of the metaphysis is often rare as it is a highly vascular region. Here we report an unusual case of non-traumatic osteonecrosis of the humerus predominantly involving the metaphysis in a post covid elderly female. The patient had a pathological fracture of humerus during the post-operative period of intertrochanteric femur fracture surgery. She was evaluated for the causes of pathological fracture and the fracture was managed with hemi replacement of the shoulder because of the extensive bone loss. The pathology here could only be explained as some sequelae of hyper inflammatory state associated with COVID-19 infection. The possible differentials are also discussed here. This case report will help clinicians to consider COVID-19 infection as a cause for non-traumatic osteonecrosis among other reported causes of osteonecrosis.

[Myeloid sarcomas of the shoulder and testis relapsing 9 years after allogenic stem cell transplantation for acute myeloid leukemia]

This report describes a 56-year-old man who was diagnosed with myeloid sarcoma (MS) of the testis and right shoulder after receiving allogenic stem cell transplantation (allo-SCT) at the age of 47 for acute myeloid leukemia (AML) with inv (16) (p13.1;q22). Nine years after allo-SCT, he complained of a painful right testicular mass. He underwent orchiectomy, and the pathologic diagnosis was MS. Inv (16) was identified by fluorescence in situ hybridization (FISH) using testicular tumor specimens. 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) revealed FDG accumulation in the right shoulder. FISH analysis of bone marrow aspirate revealed no increase in blasts and ruled out CBFB-MYH11 fusion. Reinduction chemotherapy, consolidation, and local radiation therapy for the left testis and right shoulder were administered to him. After that, he received a second allo-SCT from an unrelated donor who was HLA-matched. As of 2 years after the second allo-SCT, recurrence of neither AML nor myeloid sarcoma has been observed. The recurrence of MSs without bone marrow involvement is frequently reported in single, multiple single organs, or multiple single regions. Even if MSs recur in a distant location, combining systemic and local treatment may be a better treatment strategy.

The Subacromial Bursa: Current Concepts Review

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The subacromial bursa is a distinct anatomic structure with distinct histologic features; it plays a critical role in the symptoms of the painful shoulder and in the local healing capacity of the rotator cuff tendon.

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Treatment of pain from bursitis of the subacromial bursa largely involves nonoperative interventions; however, operative treatment may be considered in certain instances.

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Preservation of the subacromial bursa should occur whenever possible given its intrinsic trophic and pluripotent factors, which have been shown to play important roles in rotator cuff tendon pathology.

Deep-learning framework and computer assisted fatty infiltration analysis for the supraspinatus muscle in MRI

Occupation ratio and fatty infiltration are important parameters for evaluating patients with rotator cuff tears. We analyzed the occupation ratio using a deep-learning framework and studied the fatty infiltration of the supraspinatus muscle using an automated region-based Otsu thresholding technique. To calculate the amount of fatty infiltration of the supraspinatus muscle using an automated region-based Otsu thresholding technique. The mean Dice similarity coefficient, accuracy, sensitivity, specificity, and relative area difference for the segmented lesion, measuring the similarity of clinician assessment and that of a deep neural network, were 0.97, 99.84, 96.89, 99.92, and 0.07, respectively, for the supraspinatus fossa and 0.94, 99.89, 93.34, 99.95, and 2.03, respectively, for the supraspinatus muscle. The fatty infiltration measure using the Otsu thresholding method significantly differed among the Goutallier grades (Grade 0; 0.06, Grade 1; 4.68, Grade 2; 20.10, Grade 3; 42.86, Grade 4; 55.79, p < 0.0001). The occupation ratio and fatty infiltration using Otsu thresholding demonstrated a moderate negative correlation (ρ = - 0.75, p < 0.0001). This study included 240 randomly selected patients who underwent shoulder magnetic resonance imaging (MRI) from January 2015 to December 2016. We used a fully convolutional deep-learning algorithm to quantitatively detect the fossa and muscle regions by measuring the occupation ratio of the supraspinatus muscle. Fatty infiltration was objectively evaluated using the Otsu thresholding method. The proposed convolutional neural network exhibited fast and accurate segmentation of the supraspinatus muscle and fossa from shoulder MRI, allowing automatic calculation of the occupation ratio. Quantitative evaluation using a modified Otsu thresholding method can be used to calculate the proportion of fatty infiltration in the supraspinatus muscle. We expect that this will improve the efficiency and objectivity of diagnoses by quantifying the index used for shoulder MRI.

The amount of surgical correction of the main thoracic curve is the best predictor of postoperative clinical shoulder balance in patients with Adolescent Idiopathic Scoliosis

PURPOSE

This study sought to analyze factors that predict postoperative shoulder balance based on clinical photography.

METHODS

Based on inclusion criteria, 132 AIS patients were selected. Age, sex, and BMI of each patient were recorded. The following parameters were recorded from radiographs: clavicle angle, T1 tilt, the upper instrumented vertebra (UIV), lowest instrumented vertebra (LIV) thoracic kyphosis, lumbar modifier, preoperative and postoperative proximal thoracic Cobb angle, preoperative and postoperative main thoracic Cobb angle, and preoperative and postoperative thoracolumbar Cobb angle, if applicable. Two spine surgeons independently assigned the photographs shoulder balance grades based on the WRVAS (1-2 = Acceptable, 3-5 = Unacceptable). Surgeons were blinded as to whether the photographs were taken preoperatively or postoperatively. The shoulders were also graded as right high, left high, or balanced.

RESULTS

Of all variables analyzed, only main thoracic Cobb angle correction (MTCAC) showed a statistically significant relationship with postoperative shoulder balance (p = 0.01). Odds of having unacceptable shoulder balance increase by 21% for every 5° increase in MTCAC (Adjusted OR = 1.21, 95% CI 1.015-1.452). The odds of unbalanced shoulders are 4.7 times higher for patients whose MTCAC is 40° or more (p = 0.001). Inter-rater reliability was excellent (k =0 .7). Intra rater reliability was perfect for Surgeon 1 (kappa = 1.0) and showed substantial agreement for Surgeon 2 (kappa = 0.8) CONCLUSIONS: Greater correction of main thoracic Cobb angle predicts unacceptable postoperative shoulder balance with 40° of correction signifying a major dichotomy between acceptable and unacceptable.

The effects of poloxamer and sodium alginate mixture (Guardix-SG®) on range of motion after axillary lymph node dissection: A single-center, prospective, randomized, double-blind pilot study

PURPOSE

Restricted shoulder mobility is a major upper extremity dysfunction associated with lower quality of life and disability after breast cancer surgery. We hypothesized that a poloxamer and sodium alginate mixture (Guardix-SG®) applied after axillary lymph node dissection (ALND) would significantly improve shoulder range of motion (ROM) in patients with breast cancer.

METHODS

We conducted a double-blind, randomized, prospective study to evaluate the clinical efficacy and safety of Guardix-SG® for the prevention of upper extremity dysfunction after ALND. The primary outcome measure was shoulder ROM at baseline (T0) and 3 (T1), 6 (T2), and 12 months (T3) after surgery. Secondary outcome measures were the Disabilities of the Arm, Shoulder, and Hand score(DASH), pain associated with movement, which was assessed using a numeric rating scale, and lymphedema assessed using body composition analyzer.

RESULTS

A total of 83 women with breast cancer were randomly assigned to either the Guardix-SG® group or the control group. In the Guardix-SG® group (n = 37), Guardix-SG® was applied to the axillary region after ALND. In the control group (n = 46), ALND was performed without using Guardix-SG®. Comparing ROM for shoulder flexion before surgery (178.2°) and 12 months after surgery (172.3°), that was restored 12 months after surgery in the Guardix-SG® group, and there was no statistically significant difference between that at before surgery and 12 months after surgery (p = 0.182). No adverse effect was observed in either group.

CONCLUSIONS

The results of this study have shown that Guardix-SG® help improve shoulder ROM without causing adverse effects in patients who underwent breast cancer surgery. However, there was no statistically significant difference from the control group. A further large-scale study is needed to obtain a more conclusive conclusion.

TRIAL REGISTRATION

CRISKCT0003386; https://cris.nih.go.kr (20181207).

Association of Both Scapular Upward Rotation and Scapulothoracic Muscle Lengths With Shoulder Pain, Function, and Range of Movement

OBJECTIVE

Our aim was to analyze whether shoulder pain is related to scapular upward rotation (SUR) or to the lengths of the pectoralis minor and levator scapulae muscles.

METHODS

This cross-sectional, observational study was carried out in 3 primary-care centers; 54 individuals with chronic shoulder pain participated. Scapular upward rotation and the lengths of the pectoralis minor and levator scapulae muscles were assessed.

RESULTS

The level of association was small between shoulder pain and function and (1) the lengths of the pectoralis minor (r = 0.08, P = .93) and levator scapulae (r = -0.01, P = .57) muscles and (2) SUR at 45° (r = 0.17, P = .21), 90° (r = 0.08, P = .57), and 135° (r = 0.10, P = 0.45) of shoulder elevation.

CONCLUSION

The relationship was small between shoulder pain and function and (1) SUR (45°, 90°, and 135° of shoulder elevation) and (2) the lengths of the pectoralis minor and levator scapulae muscles. Thus, the use of SUR and pectoralis minor and levator scapulae lengths in shoulder assessment should be undertaken with caution. Other factors such as psychological factors, central/peripheral sensitization, and intrinsic properties of the tissue have to be taken into account.

Risk factors of impairment of shoulder function after axillary dissection for breast cancer

OBJECTIVES

Postoperative shoulder joint dysfunction has been observed at a certain rate after breast cancer surgery with axillary lymph node dissection. The purposes of this study were to verify the feasibility and effects of home-based exercise using a DVD and clarify the target of intensive intervention with physiotherapy by identifying the factors that cause postoperative shoulder dysfunction.

METHODS

The study comprised 237 female patients who underwent breast cancer surgery with axillary lymph node dissection, whose data were acquired until 3 months postoperatively. All patients were instructed to exercise at home using a DVD. Range of motion (ROM) of shoulder flexion and abduction and the disability of the arm, shoulder, and hand (DASH) score were measured before surgery, 1 week and 1, 2, and 3 months after surgery. As factors influencing the recovery of shoulder ROM at 3 months after surgery, the presence or absence of radiation and factors up to 1 month after surgery (age, body mass index, the relationship between operated side and dominant side of the hand, treatment modalities, and complications).

RESULTS

Shoulder ROM and DASH scores had gradually recovered from 1 week to 3 months postoperatively. As the results of the multivariate analysis, the factors that were associated with the recovery of ROM of shoulder flexion at 3 months were the side of surgery corresponding to the dominant hand (negative factor) and the presence of paresthesia at 1 week postoperatively (positive factor) (p < 0.05). Radiation therapy and the side of surgery corresponding to the dominant hand were negative factors for the recovery of shoulder abduction (p < 0.01). Regarding the feasibility of the home exercise, 214/229 (93.4%), 172/210 (81.9%), and 139/206 (67.5%) of patients performed exercise at least once a day at 1, 2, and 3 months after surgery, respectively.

CONCLUSION

Our result indicated that the side of surgery corresponding to the dominant hand was the inhibiting factor for recovery for both shoulder flexion and abduction at 3 months after surgery. Home-based exercise with DVD was considered feasible. For the verification of this effectiveness, a randomized control study should be planned in the future.

Solitary nodule on the shoulder of an 11-year-old child

Plexiform fibrohistiocytic tumor is an uncommon soft tissue neoplasm of intermediate malignancy, most frequently occurring as a painless, slow-growing nodule that shows a distinct predilection for children and young adults. We report a healthy 11-year-old boy presenting with a 1-year history of an asymptomatic cutaneous nodule on his left shoulder. Histopathological and immunohistochemical analysis confirmed a diagnosis of plexiform fibrohistiocytic tumor. Despite following a usually benign clinical course, this neoplasm is prone to frequent local recurrence and occasional metastatic ability. It should be considered in the differential diagnosis of an enlarging nodule in pediatric patients.

The use of a patch to augment rotator cuff surgery - A survey of UK shoulder and elbow surgeons

Background

Rotator cuff tears are a common cause of shoulder pain and can result in prolonged periods of pain, disability and absence from work. Rotator cuff repair surgery is increasingly used in an attempt to resolve symptoms but has failure rates of around 40%. There is a pressing need to improve the outcome of rotator cuff repairs. Patch augmentation increasingly being used within the NHS in an attempt to reduce repair failures. The aim of this survey was to determine current UK practice and opinion relating to the factors that influence choice of patch, current patient selection and willingness to assist with generation of improved evidence.

Methods

An online survey was sent to the surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent demographics, experience with patches, indications for patch augmentation and willingness to be involved in a randomised trial of patch augmented rotator cuff surgery.

Results

The response rate was 105/550 (19%). 58% of respondents had used a patch to augment rotator cuff surgery. 70% of patch users had undertaken an augmented repair within the last 6 months. A wide surgical experience in augmentation was reported (ranging 1 to 200 implants used). However, most surgeons reported low volume usage, with a median of 5 rotator cuff augmentation procedures performed. At least 10 different products had been used. Most of the patches used were constructed from human decellularised dermis tissue, although porcine derived and synthetic based patches had also been used. Only 3–5% stated they would undertake an augmented repair for small tears across ages, whereas 28–40% and 19–59% would do so for large or massive tears respectively. When assessing patient suitability, patient age seemed relevant only for those with large and massive tears. Half of the surgeons reported an interest in taking part in a randomised controlled trial (RCT) evaluating the role of patch augmentation for rotator cuff surgery, with a further 22% of respondent’s undecided.

Conclusions

A variety of patches have been used by surgeons to augment rotator cuff repair with a wide range of operator experience. There was substantial uncertainty about which patch to use and differing views on which patients were most suitable. There is a clear need for robust clinical evaluation and further research in this area.

Randomized control trial of ultrasound-guided erector spinae block versus shoulder periarticular anesthetic infiltration for pain control after arthroscopic shoulder surgery: Study protocol clinical trial (SPIRIT compliant)

INTRODUCTION

Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain.

METHODS

This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat.

DISCUSSION

This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block.

TRIAL REGISTRATION NUMBER

NCT03691922; Recruited Date of registration: October 2, 2018.

Dirofilaria hongkongensis infection presenting as recurrent shoulder mass

In 2012, a novel canine Dirofilaria species, D. hongkongensis was identified in Hong Kong that caused human diseases and subsequently reported in an Austrian traveller returning from the Indian subcontinent. Here we present a case of human infection by D. hongkongensis manifested as recurrent shoulder mass. Diagnosis was achieved by cox1 gene sequencing of the excised specimen. The case illustrated that parasitic infection represents an important differential diagnosis for musculoskeletal lesions.

Lower subscapular nerve transfer for axillary nerve repair in upper brachial plexus palsy

BACKGROUND

The potential to utilize the lower subscapular nerve for brachial plexus surgery has been suggested in many anatomical studies. However, we know of no studies in the literature describing the use of the lower subscapular nerve for axillary nerve reconstruction to date. This study aimed to examine the effectiveness of this nerve transfer in patients with upper brachial plexus palsy.

METHODS

Of 1340 nerve reconstructions in 568 patients with brachial plexus injury performed by the senior author (P.H.), a subset of 18 patients underwent axillary nerve reconstruction using the lower subscapular nerve and constitutes the patient group for this study. The median age was 48 years, and the median time between trauma and surgery was 6 months. A concomitant radial nerve injury was found in 8 patients.

RESULTS

Thirteen patients completed a minimum follow-up period of 24 months. Successful deltoid recovery was defined as (1) muscle strength MRC grade ≥ 3, (2) electromyographic signs of reinnervation, and (3) increase in deltoid muscle mass. Axillary nerve reconstruction was successful in 9 of 13 patients, which represents a success rate of 69.2%. No significant postoperative weakness of shoulder internal rotation or adduction was observed after transecting the lower subscapular nerve.

CONCLUSIONS

The lower subscapular nerve can be used as a safe and effective neurotization tool for upper brachial plexus injury, having a success rate of 69.2% for axillary nerve repair. Our technique presents a suitable alternative for patients with concomitant radial nerve injury.

Survival, Tumor Recurrence, and Function Following Shoulder Girdle Limb Salvage at 24 to 35 Years of Follow-up

Limb salvage is the treatment of choice for malignant shoulder girdle tumors; however, there is a paucity of data examining the long-term outcome. The authors have previously reported on a cohort of patients at short- and mid-term follow-up. The purpose of this study was to report the long-term outcome of shoulder reconstruction in terms of oncological and functional outcome. The authors reviewed 53 patients who underwent a limb salvage procedure for treatment of a tumor of the shoulder girdle. At a mean of 28 years following the resection, 76% of surviving patients were contacted and administered functional outcome scores using the Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage (TESS). The 20-year survival and recurrence-free survival were 79% and 80%, respectively. Likewise, the 20-year revision survival was 75%, with a limb salvage rate of 94%. At last follow-up, the mean MSTS rating and TESS score were 75% and 85%, respectively, with 9 patients having improvement in their MSTS rating from the previous findings. Limb salvage following resection of shoulder girdle tumor resulted in acceptable means of oncological outcome and function. Some patients continued to experience improvements in functional outcome even at late (>20 years) follow-up. [Orthopedics. 2019; 42(6):e514-e520.].

[Suspected traumatic posterior shoulder luxation]

BACKGROUND An obstetric brachial plexus lesion arises during childbirth as a consequence of excessive lateral traction of the neonate's head during shoulder dystocia. A small number of patients do not experience spontaneous recovery and secondary glenohumeral deformities can arise due to rotator cuff imbalance. CASE DESCRIPTION A 34-year-old man of Syrian descent with a history of a conservatively treated right-sided obstetric brachial plexus lesion went to the accident and emergency department (A and E) with acute pain in the right shoulder. Additional X-ray diagnostics suggested a posterior shoulder luxation, but attempts to relocate the glenohumeral joint in A and E failed. An additional CT scan of the shoulders revealed a severe right-sided dysplasia of the glenohumeral joint, with severe retroversion and posterior luxation of a rotated humeral head. After 3 weeks of relative rest through use of a sling and pain relief with an NSAID the pain had diminished and the patient had resumed his daily activities. CONCLUSION Posterior shoulder luxation can occur as a complication of obstetric brachial plexus lesion. Closed reduction is not of any use in these cases. The expertise of a specialized multidisciplinary team is indispensable for providing a patient with obstetric brachial plexus lesion with the best advice on treatment.

The impact of pre-existing shoulder diseases and traumatic injuries of the shoulder on adhesive capsulitis in adult population: A population-based nested case-control study

Adhesive capsulitis (AC) is a common chronic disorder for adult patients; however, whether a history of pre-existing shoulder diseases may affect the development of AC is still not fully understood. We aimed to investigate the incidence and prevalence of AC and to assess the association of pre-existing shoulder diseases and traumatic injuries of the shoulder with the development of AC in adults.This retrospective population-based cohort and nested case-control study used data from the National Health Institute Research Database of Taiwan. A total of 24,414 patients aged 20 years or older and with a diagnosis of AC were identified between 2000 and 2013. We calculated the incidence of AC for each year during the study period. In addition, these AC patients were matched with controls (n = 97,656) in a ratio of 1:4 based on age, gender, and index date. Univariate and multivariate logistic regression models were performed to identify variables associated with AC.Females and patients aged 50 to 69 years had higher age-gender standardized incidence and prevalence of AC than their counterparts. Multivariate analyses showed that after adjusting for relevant covariates, pre-existing shoulder diseases of calcific tendinitis (odds ratio [OR] = 8.74, 95% confidence interval [CI] = 5.66-13.5), biceps tendinitis (OR = 7.93, 95% CI = 5.33-11.79), rotator cuff syndrome (OR = 6, 95% CI = 5.26-6.85), osteoarthritis (OR = 4.27, 95% CI = 3.44-5.3), and impingement syndrome (OR = 3.13, 95% CI = 2.64-3.71), as well as fracture (OR = 4.51, 95% CI = 3.82-5.34) and dislocation (OR = 3.57, 95% CI = 2.35-5.45) of the shoulder were significantly associated with AC risk.Higher odds of AC were observed among patients with pre-existing shoulder conditions. This study highlights the need to consider differences in AC risk among patients with various types of shoulder diseases and traumatic injuries of the shoulder.

Gorham-Stout Syndrome of the Shoulder Girdle Successfully Controlled by Antiresorptive Agents: A Report of 2 Cases

CASE

Gorham-Stout disease (GSD) is a rare disorder characterized by massive bone destruction. Consensus is lacking on the effective treatment strategies for GSD. This report presents 2 cases of GSD, a 47-year-old man and a 72-year-old woman, involving the shoulder girdle which were successfully controlled by antiresorptive agents including bisphosphonates and denosumab, the antireceptor activator of nuclear factor-κB ligand antibody.

CONCLUSIONS

These 2 cases suggest that antiresorptive agents targeting osteoclasts can be efficacious therapeutic options for GSD. This is the first case of GSD we are aware of which showed good response to denosumab treatment.

Shoulder osteoarthritis in a European saber-toothed cat (Homotherium latidens) from the Lower Palaeolithic site of Schöningen (Germany)

Evaluation of a right ventral scapula fragment from a mature Homotherium latidens from Schöningen, Germany (337-300 ka before present - MIS 9) revealed lesions consisting of an osteophyte at the caudal border of the glenoid cavity, and a large, multilobular, cystic feature in the medio-caudal glenoid cavity. Based on the type of lesions, their localization, their severity, and exclusion of several nutritional and other etiologies such as immune mediated disease, joint infection (septic arthritis), and joint tumors, we conclude that the lesion was caused by trauma or age-related shoulder osteoarthritis (or possibly both). We cannot speculate whether the condition was symptomatic, but if it was, the animal must have functioned well enough to hunt or scavenge, since it survived a significant period of lesion development.

A circular depression at the spinoglenoid notch of a prehistoric Andean scapula: Plausible evidence of suprascapular nerve entrapment by a paralabral cyst

While intraosseous cysts have been described in the paleopathological literature, it is rare to find reports concerning effects of soft tissue cysts, although they are relatively common in clinical contexts. Here we present plausible evidence of an extraosseous paralabral cyst, seen in an adult scapula from a Late Intermediate period commingled tomb (ca. AD 1200) at the northern highland site of Marcajirca, Ancash, Peru. The scapula demonstrated a smooth-sided concave depression at the spinoglenoid notch. The depression was notable for its regular appearance, with no bone deposition or destruction. Rather than reflect an intraosseous pathology, the defect likely resulted from pressure erosion from a space-occupying mass. A narrow strip of flattened bone connected the depression to the posterior-superior aspect of the glenoid. The location and morphology of the depression and its connection with the glenoid are consistent with the effects of a paralabral cyst that arose secondary to a tear of the posterior-superior glenoid labrum. A labral tear may act as a one-way valve permitting fluid to flow along a path of least resistance, often to the spinoglenoid notch. A cyst at the spinoglenoid notch would compress the suprascapular nerve, causing weakened function of infraspinatus and its eventual atrophy.

Pigmented Villonodular Synovitis Masquerading as a Metastasis: Imaging Features and Coaxial Needle Biopsy Technique

Pigmented Villonodular Synovitis (PVNS) of the shoulder is rare. We present a patient with locally recurrent tonsillar squamous cell carcinoma (SCC) and newly identified soft tissue lesion of the right shoulder exhibiting similar focal FDG-PET CT uptake. Biopsy demonstrated features consistent with pigmented villonodular synovitis (PVNS). We discuss imaging features and describe a ' two needle,' coaxial biopsy technique.

[A woman with swollen shoulders]

A 65-year-old woman, who had been suffering from erosive rheumatoid arthritis, presented with swollen shoulders. Also, she experienced a weary feeling in her left arm. An MRI scan of the left shoulder showed multiple nodules ('rice bodies') in the subacromial-subdeltoid bursa. We extracted the nodules via a deltopectoral approach, after which the symptoms disappeared.

Constant-Murley Score: systematic review and standardized evaluation in different shoulder pathologies

PURPOSE

The objective of this study was to evaluate the psychometric properties of the Constant-Murley Score (CMS) in various shoulder pathologies, based on a systematic review and expert standardized evaluations.

METHODS

A systematic review was performed in MEDLINE and EMBASE databases. Titles and abstracts were reviewed and finally the included articles were grouped according to patients' pathologies. Two expert evaluators independently assessed the CMS properties of reliability, validity, responsiveness to change, interpretability and burden score in each group, using the EMPRO (Evaluating Measures of Patient Reported Outcomes) tool. The CMS properties were assessed per attribute and overall for each considered group. Only the concept and measurement model was assessed globally.

RESULTS

Five individual pathologies (i.e. subacromial, fractures, arthritis, instability and frozen shoulder) and two additional groups (i.e. various pathologies and healthy subjects) were considered. Overall EMPRO scores ranged from 58.6 for subacromial to 30.6 points for instability. Responsiveness to change was the only quality to obtain at least 50 points across all groups, but for frozen shoulder. Insufficient information was obtained in relation to the concept and measurement model and great variability was seen in the other evaluated attributes.

CONCLUSIONS

The current evidence does not support the CMS as a gold standard in shoulder evaluation. Its use is advisable for subacromial pathology; but data are inconclusive for other shoulder conditions. Prospective studies exploring the psychometric properties of the scale, particularly for fractures, arthritis, instability and frozen shoulder are needed.

LEVEL OF EVIDENCE

Systematic review.