Management of glenoid bone loss with impaction and structural bone grafting in reverse shoulder arthroplasty

INTRODUCTION

Glenoid bone loss is a commonly encountered problem in complex primary and revision shoulder arthroplasty. Addressing glenoid bone loss is critical to avoid complications like early loosening, impingement, notching and instability. A large number of techniques like bone grafting using autograft or allograft, eccentric reaming, augmented base plates, patient-specific instrumentations and custom-made implants are available to tackle bone loss.

MATERIALS AND METHODS

We prospectively collected the data of all patients with glenoid defects undergoing primary or revision reverse shoulder replacement between 2004 and 2017. This included demographic data, ranges of motion, Constant-Murley score and Subjective Shoulder Value (SSV). A pre-operative CT scan was done as well to plan the surgery and calculate the glenoid version. At each follow-up, the clinical function and shoulder scores were assessed. Additionally, the radiographs were assessed for graft incorporation, evidence of lysis and calculation of glenoid version.

RESULTS

Between 2004 and 2017, 37 patients underwent glenoid bone grafting during reverse shoulder arthroplasty. Average age was 72 years (range 46-88). Indications for surgery were cuff tear arthropathy (6 patients); revision of failed other prosthesis (23); primary osteoarthritis (4); rheumatoid arthritis (3); and second-stage revision for infection (1). The glenoid defect was contained in 24 patients, and therefore, impaction graft with a combination of bone graft substitute and/or humeral head autograft was performed. In 13 patients the glenoid defect was severe and uncontainable and therefore a graft-implant composite glenoid was implanted using humeral head autograft or allograft. Average follow-up was 3.6 years (range 1-10). Mean Constant score improved from 34 before surgery to 63 after surgery. Mean SSV score improved from 0.9/10 to 8.3/10. Active movements improved significantly with forward elevation increasing from 54° to 123°; abduction from 48° to 123°; external rotation from 24° to 38°; internal rotation from 57° to 70°. Radiographs at final follow-up showed no radiolucencies around the glenoid component and no evidence of loosening of the implant. In 2 cases there was a grade I notching. There was 100% survivorship at the last follow-up.

CONCLUSION

Impaction bone grafting along with structural grafting when required is an effective and reproducible way of managing severe glenoid bone loss. This technique gives consistent and good clinical and radiological results.

The "purse string" technique for anterior glenohumeral instability: long-term results 7-13-year follow-up

PURPOSE

The "Purse-String Technique" (PST) is an arthroscopic horizontal mattress suture technique for recurrent anterior shoulder instability that uses a single double-loaded suture anchor at the 4-o' clock position, achieving a Bankart labral repair and an infero-superior capsular shift. In this study, we describe the long-term results of the PST.

METHODS

The study included 69 individuals (70 shoulders), with a mean age of 30 years, who had recurrent post-traumatic anteroinferior instability. A purse-string suture anchor at the 4-o'clock position was used to address the Bankart lesion and capsular laxity, recreating the anterior glenoid bumper. All patients were assessed via telephone interview at a mean of 116 months after surgery (7-13-year follow-up).

RESULTS

Postoperatively, the mean Constant score was 94, mean Rowe score was 93 and mean Walch-Duplay score was 89. 89% of patients resumed their preinjury sport activities, with 61% of patients achieving preinjury levels and most professional athletes returning to full activity. Seven patients had recurrent dislocation postoperatively (10% failure rate). Of these patients, three had revision arthroscopic stabilization, one patient had revision arthroscopic stabilization with remplissage, two had a Latarjet procedure, whereas one patient decided to seek no further treatment.

CONCLUSION

The long-term results of PST are promising, with a low failure rate, high patient satisfaction and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV; Case series; Treatment study.

Reverse shoulder replacement versus hemiarthroplasty for proximal humeral fracture in elderly patients: a systematic review

This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.

Acute versus delayed reverse total shoulder arthroplasty for proximal humeral fractures: a consecutive cohort study

BACKGROUND

The treatment of displaced proximal humeral fractures (PHFs) remains controversial. Open reduction-internal fixation (ORIF) can be challenging, especially in elderly patients with poor bone quality, whereas hemiarthroplasty has had unpredictable outcomes. Conservative treatment may result in severe fracture sequelae with poor outcomes, requiring late reverse total shoulder arthroplasty (RTSA) in many cases. The past few years have seen a shift toward the use of RTSA for the treatment of PHFs. The aim of this study was to compare the outcomes of RTSA between patients with acute fractures and patients who underwent delayed RTSA for fracture sequelae. Our hypothesis was that the outcomes of RTSA for acute PHFs would be better than those of delayed RTSA for fracture sequelae.

METHODS

We followed up 36 patients with a mean age of 79.1 years who underwent primary RTSA for acute PHFs and 56 patients with a mean age of 72.1 years who underwent RTSA in delayed fashion for fracture sequelae, including failed ORIF. The minimum follow-up period was 24 months. The mean follow-up period was 39.3 months in the acute RTSA group and 56.6 months in the delayed RTSA group. Demographic data, radiographs, and surgery data were prospectively collected and analyzed. At final follow-up, range of motion and radiographic analysis findings, as well as the Subjective Shoulder Value (SSV) and Constant score (CS), were recorded.

RESULTS

The clinical results favored the group undergoing acute RTSA for acute PHFs, with a mean SSV of 8.3 of 10 and adjusted CS of 88.9% compared with a mean SSV of 8.0 of 10 and adjusted CS of 77.6% in the group undergoing late RTSA for fracture sequelae-but without statistically significant differences between the groups. Although the acute RTSA group showed slightly better range-of-motion values, no statistically significant differences were found between the groups. No intraoperative complications occurred. The time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group.

CONCLUSION

Although there were no statistically significant differences in outcomes between early RTSA for acute PHFs and late RTSA for fracture sequelae, the time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. Therefore, we advocate early RTSA for acute PHFs in elderly patients to provide a quicker recovery and an early return to good predictable outcomes with a much shorter period of pain and discomfort. In cases of failed conservative treatment, malunion, or failed ORIF, salvage RTSA has the potential to provide a good outcome.

Accelerated rehabilitation following reverse total shoulder arthroplasty

BACKGROUND

Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, and published literature is sparse, as is the quantity and quality of research evidence. The aim of this study is to outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and for 3 weeks.

MATERIALS AND METHODS

Between July 2005 and October 2017, a total of 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 and 3 weeks' postoperative immobilization, respectively, for groups 1 and 2, and no immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, and 12 months, and yearly thereafter postoperatively. Constant score (CS), Subjective Shoulder Value (SSV), patient satisfaction, and pain scores were used at each appointment and patients assessed both clinically and radiographically.

RESULTS

Mean age at surgery was 76 years (range 40-93). At 1-year follow-up, the CS improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n = 114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n = 125), and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n = 118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2, and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10, and 8.1/10 for groups 1, 2, and 3, respectively. Mean range of motion (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2, and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain, and ROM between the 3 groups. Less postoperative complications were observed in group 3 (No immobilization).

CONCLUSION

Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms noninferiority of the accelerated rehabilitation regime with fewer postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.

Minimally invasive fixation with modified palm tree technique for proximal humerus fractures: Outcomes in a series of 132 patients

INTRODUCTION

Various surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique.

METHODS

A retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed.

RESULTS

Between 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty.

CONCLUSION

This technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.

Software simulations of changing offsets and thus soft tissue tension when revising anatomic to reverse total shoulder arthroplasty in convertible platform systems

BACKGROUND

Revision shoulder arthroplasty may involve the need to remove a well-fixed humeral stem. To avoid this, convertible platform systems have been introduced. The biomechanics of reverse total shoulder arthroplasty (rTSA) differs from anatomic shoulder arthroplasty (aTSA). The different humeral osteotomy and soft tissue tension may jeopardize the optimal results of the converted rTSA. The aim was to evaluate the radiographic parameters of soft tissue distraction when converting an aTSA to rTSA in a platform system and assess the capability of conversion without "over-stuffing" the shoulder in the "best-case scenario".

METHODS

Radiographic analysis of soft tissue distraction parameters: difference in acromio-humeral distance, difference in lateral humeral offset and difference in latero-inferior displacement were evaluated in aTSA and in the converted rTSA in six different implants. Image analysing software was used on 10 non-deformed osteoarthritic shoulder X-rays to simulate conversion.

RESULTS

The greatest increase in arm length was found for Tornier Ascend Flex (26.8 ± 3.6 mm) while the smallest increase was observed with Lima SMR (19.3 ± 4 mm). The humerus remained most lateralized with the Zimmer Anatomical/Inverse ( - 1.4 ± 2.9 mm) while Lima SMR ( - 15.8 ± 2.7 mm) was more medialized. The greatest increase in latero-inferior distance was found in the onlay systems. A group analysis of onlay rTSA showed an increase of 46% in arm length (p < 0.0001), 83% larger humeral offset (p < 0.0001) and 144% increase in latero-inferior distraction (p < 0.0001) when compared to inlay rTSA.

CONCLUSION

The conversion of aTSA to rTSA using a convertible platform system may lead to significant increase in radiographic parameters corresponding to soft tissue tension. This may alter the biomechanics, restrict the convertibility or jeopardize the optimal clinical outcome of rTSA even in the best-case scenario.

Do elderly patients gain as much benefit from arthroscopic rotator cuff repair as their younger peers?

BACKGROUND

This study was conducted to ascertain whether patients aged older than 75 years achieve outcomes after arthroscopic rotator cuff repair comparable to younger patients.

METHODS

Arthroscopic cuff repair was performed in 60 shoulders of 59 patients aged older than 75 years. A control group of 60 younger patients, matched for sex, tear size, and American Society of Anesthesiology Functional Classification grade were included. Surgery occurred from 2006 to 2016. Prospective outcomes were the Constant score (CS), Subjective Shoulder Value, pain, satisfaction, and operative complications. Mean follow-up was 29 months.

RESULTS

The elderly group was a mean age of 78 years compared with 59 years for controls. Tear sizes were 25 massive, 20 large, 12 medium, and 3 small. The CS improved by 25.1 points in elderly patients compared with 23.7 points for controls (P = .742). Pain improved by 7.5 of 15 in elderly patients vs. 6.2 of 15 in controls (P = .055). Fifty-five of 59 older patients were satisfied compared with 52 of 60 controls (P = .378). The overall complication rate did not differ between the groups (P = .509). Both groups had 1 infection and 1 stiffness. An acromioclavicular joint cyst developed in 1 younger patient, and a traumatic retear occurred in 1 patient. Subsequent reverse total shoulder arthroplasty was performed in 4 elderly patients at a mean of 28 months after cuff repair. Massive tears had higher risk for subsequent reverse total shoulder arthroplasty (P = .026).

CONCLUSION

Elderly patients benefit as much from arthroscopic rotator cuff repair as their younger counterparts. Similar improvements in CS, Subjective Shoulder Value, pain, and satisfaction occurred for both elderly and control patients. Arthroscopic repair was safe and effective in both groups. Even elderly patients with massive tears showed clinically significant improvements. Arthroscopic rotator cuff repair should be considered as a valuable treatment irrespective of age.

Subacromial impingement syndrome: management challenges

The painful shoulder is the most common condition seen in specialist shoulder clinics. It is often associated with lack of range of motion and reduced shoulder function. Lack of sleep and difficulties in performing basic daily life activities are common findings. Subacromial Impingement Syndrome (SAIS) has been considered as the most common cause of shoulder pain since it was described in 1852. Charles Neer, in 1972, described the presence of a "proliferative spur and ridge" on the undersurface of the acromion, which needs to be removed to improve the symptoms (acromioplasty). Neer's "impingement" hegemony was undisputed for at least 30 years. A more extensive knowledge of the pathogenesis of SAIS, however, has led authors to challenge the role of "impingement" in the shoulder pain and the role of surgical intervention. The aim of this review was to understand if there is still a role for surgical decompression in patients with SAIS. A literature review was performed in PubMed, PEDro, Embase, and the Cochrane Central Register of Controlled Trials using impingement, subacromial space, rotator cuff tears, tendinopathy, and tendinitis as key words. Randomized clinical trials (RCTs) with long-term follow-up comparing surgical intervention and conservative treatments in SAIS were preferred; however, prospective articles studying the outcome of surgical decompression and physiotherapy were also included. The majority of the studies showed no difference in the outcome between patients randomized to surgical decompression or conservative management. However, some studies reported better results after surgery, especially in the long term. Interpretation of the results is very difficult as most of the studies are of poor quality and have short follow-up. In our opinion, the type of subacromial lesion needs to be considered; this may offer an explanation to the difference in severity of symptoms and to the varying degrees of response to certain treatments, including surgery. Further studies are mandatory to better understand the role of surgery in SAIS.

The "Parachute" Technique: A Simple and Effective Single-Row Procedure to Achieve an Increased Contact Area Between the Cuff-Tendon and Its Footprint

Many techniques of arthroscopic rotator cuff repair have been described. No significant differences in clinical outcomes or rerupture rates have been observed when comparing single-row with double-row methods. Not all single- and double-row repairs are the same. The details of the technique used are crucial. It has been shown that the suture-tendon interface is the weakest point of the reconstruction. Therefore, the biomechanical properties of rotator cuff repairs might be influenced more by the suture configuration than by the number of anchors or by the number of rows involved. Techniques that secure less amount of tendon over a smaller area of the healing zone might be expected to have higher failure rates. The way the sutures of the "parachute technique" are configured represents a quadruple mattress that increases the contact and pressure between the tendon and its footprint and increases the primary load to failure of the repair. We present a simple and effective single-row technique that involves the biomechanical and biological advantages related to the increased contact area and pressure between the cuff and its footprint.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study

BACKGROUND

Reverse shoulder prostheses are increasingly used in recent years for treatment of glenohumeral arthropathy with deficient rotator cuff. Bone preservation is becoming a major goal in shoulder replacement surgery. Metaphyseal humeral components without a stem were developed to minimize bone resection and preserve bone. This study evaluated the clinical and radiologic outcomes at 2 to 7 years using a novel short metaphyseal reverse total shoulder arthroplasty (rTSA) prosthesis without a diaphyseal stem.

METHODS

Between 2005 and 2010, 102 consecutive patients underwent rTSA with this implant, and 98 (20 men, 78 women) were available for follow-up. Mean age was 74.4 years (range, 38-93 years). Indications were cuff tear arthropathy, 65; fracture sequelae, 12; rheumatoid arthritis, 13; failed rotator cuff repair, 3; cuff deficiency with loosening of anatomic prosthesis, 3; and acute trauma, 2; with 17 of these as revisions.

RESULTS

Patients' satisfaction (Subjective Shoulder Value) improved from 8 of 100 to 85 of 100. The Constant score improved from 14 to 59 (age- and sex-adjusted, 86; P < .0001). Range of motion improved from 47° to 129° in elevation, 10° to 51° in external rotation, and 21° to 65° in internal rotation. Radiographic analysis showed no lucencies, subsidence, or stress shielding around the humeral or glenoid components. Glenoid notching was found in 21 patients (18 grade 1-2; 3 grade 3).

CONCLUSIONS

The short metaphyseal rTSA design without a diaphyseal stem shows encouraging short- to midterm results, with excellent pain relief and shoulder function, restoration of good active range of motion, and high patient satisfaction scores. The design of this implant seems to result in improved rotational movements, low incidence of glenoid notching, and no implant loosening, subsidence, or stress shielding.

In vitro effects of resveratrol on oxidative stress in diabetic platelets

To evaluate the in vitro effects of resveratrol (RSV) incubation on platelets from compensated and decompensated diabetic patients in order to use it as an adjuvant therapy. The study was performed on 77 diabetic patients and divided into two phases: 29 compensated and 48 decompensated diabetic platelets were analyzed at recruitment (T₀) and after in vitro RSV incubation (20 μg/ml) for 3 h at 37 °C (T₁). Lipoperoxide and nitric oxide (NO) levels, superoxide dismutase (SOD) and Na(+)/K(+) ATPase activities, total antioxidant capacity (TAC), and membrane fluidity tested by anisotropy of fluorescent probes TMA-DPH and DPH were determined. In vitro RSV incubation counteracts oxidative damage associated with diabetes and its complications; it is able to improve platelet function through augmented membrane fluidity and Na(+)/K(+) ATPase activity; it enhances antioxidant systems' functionality by increasing NO levels, SOD activity, and TAC and by decreasing lipoperoxide levels in both compensated and decompensated patients. Such platelet functionality enhancement suggests a new method of secondary prevention of complications associated with platelet dysfunction. Being free from one of the major risks associated with many antidiabetic agents, it can be assumed that RSV utilization in the diabetic diet may have a preventive and protective role in the progression of diabetic oxidative damage.

Acromioclavicular joint acceleration-deceleration injury as a cause of persistent shoulder pain: Outcome after arthroscopic resection

BACKGROUND

Shoulder pain in general and acromioclavicular joint (ACJ) pain specifically is common after acceleration-deceleration injury following road traffic accident (RTA). The outcome of surgical treatment in this condition is not described in the literature. The aim of the present study was to report the outcome of arthroscopic resection of the ACJ in these cases.

MATERIALS AND METHODS

Nine patients with localized ACJ pain, resistant to nonoperative treatment were referred on an average 18 months after the injury. There were 3 male and 6 females. The right shoulder was involved in seven patients and the left in two. The average age was 38.9 years (range 29-46 years). All presented with normal X-rays but with torn acromioclavicular joint disc and effusion on magnetic resonance imaging (MRI). Arthroscopic ACJ excision arthroplasty was performed in all patients.

RESULTS

At a mean followup of 18 month, all patients had marked improvement. The Constant score improved from 36 to 81, the pain score from 3/15 to 10/15 and the patient satisfaction improved from 3.5/10 to 9.3/10.

CONCLUSION

Arthroscopic ACJ excision arthroplasty, gives good outcomes in patients not responding to conservative management in ACJ acceleration-deceleration injury.

Medium to long-term outcome of thoracoscapular arthrodesis with screw fixation for facioscapulohumeral muscular dystrophy

BACKGROUND

Shoulder girdle muscle weakness is the most constant feature of facioscapulohumeral muscular dystrophy and leads to scapular winging. Mechanical fixation of the scapula to the thoracic wall provides a stable fulcrum on which the deltoid muscle can exert its action on the humerus. The aim of this study was to evaluate the medium to long-term outcome of thoracoscapular arthrodesis with screw fixation (the modified Howard-Copeland technique).

METHODS

All patients with facioscapulohumeral dystrophy who underwent thoracoscapular arthrodesis with screw fixation and bone-grafting from July 1997 to July 2010 were retrospectively reviewed. Preoperative and postoperative clinical assessment included active shoulder elevation, the Constant score, a patient satisfaction score, and cosmetic satisfaction. Union was determined both clinically and radiographically.

RESULTS

Thoracoscapular arthrodesis was performed in thirty-five shoulders in twenty-four patients; eleven patients underwent bilateral procedures. The principal study group consisted of thirty-two shoulders in twenty-one patients with a minimum follow-up of twenty-four months (mean, eighty-eight months; range, twenty-four to 174 months). The mean Constant score increased from 30 (range, 17 to 41) preoperatively to 61 (range, 30 to 90) postoperatively. The mean satisfaction score increased from 1 (range, 0 to 4) to 8.4 (range, 4 to 10). Early complications consisted of one pneumothorax, one superficial wound infection, and four early failures, two of which were associated with noncompliance with the postoperative regimen. Late complications consisted of one posttraumatic fracture resulting in loosening and one painful nonunion; both were treated successfully with revision.

CONCLUSIONS

Thoracoscapular arthrodesis with screw fixation prevented scapular winging and improved short-term and long-term shoulder function in patients with facioscapulohumeral dystrophy.

LEVEL OF EVIDENCE

Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

The "anchor shape" technique for long head of the biceps tenotomy to avoid the popeye deformity

Surgical options for symptomatic pathologies of the long head of the biceps (LHB) include tenotomy and tenodesis. Tenotomy is surgically simple and quick, does not require immobilization, and avoids implant complications. However, it is associated with residual "Popeye" muscle deformity and biceps muscle cramps. Tenodesis avoids Popeye deformity, but it is technically a more difficult operation with a longer rehabilitation period and possible implant complications. The purpose of this report is to describe a novel technique for LHB tenotomy that avoids the Popeye muscle deformity. Before releasing the LHB from its anchor over the superior labrum, this technique consists of making an oblique incision, involving 50% of the tendon, distal to its attachment at the superior labrum. A second standard complete tenotomy incision is made about 1.5 cm medial to the oblique incision. The remaining stump of the LHB at the tendon-labrum junction is resected. The first incision, an oblique incomplete incision, allows the remnant of the LHB to open up and form an "anchor shape" that anchors the LHB at the articular entrance of the bicipital groove, thus decreasing the risk of Popeye deformity.

The 'hand squeeze' test for posterior 'muscle patterning instability' of the shoulder

Muscular patterning can be a contributor of positional posterior shoulder instability. Failure to recognize this pattern may lead to unnecessary surgical treatment with high failure rate. We analyzed the results of a new simple clinical test (hand squeeze test). The test is regarded positive, if during squeezing with the contralateral hand and elevation of the involved arm, in pronation, no posterior shoulder dislocation occurs. The test is regarded negative if posterior dislocation does occur regardless of the "hand squeeze". The patients with positive test were treated conservatively. Ten patients (12 shoulders) were treated between July 2006 and July 2010. The 'hand squeeze' test was positive in 8 patients (10 shoulders) and negative in 2 patients (2 shoulders). Both patients with a negative sign had structural lesions in the glenohumeral joint confirmed on arthro-MRI and were treated operatively.

Arthroscopically assisted internal fixation of the symptomatic unstable os acromiale with absorbable screws

BACKGROUND

Symptomatic meso- type os acromiale is a common pathology with inconsistent outcomes of treatment with various surgical techniques. We report the outcome of a new technique for arthroscopic fusion of symptomatic os acromiale with absorbable screws.

MATERIALS AND METHODS

The study included 8 shoulders in 8 patients with symptomatic meso- type os acromiale who were treated with the use of a new technique for arthroscopic fusion with absorbable screws. The mean age was 54 years (range, 38-67 years), and the mean time from onset of symptoms to surgery was 18 months (range, 9-25 months). No patients reported a specific traumatic event before the onset of symptoms, and all noted the insidious onset of pain with no precipitating event.

RESULTS

The average length of follow-up was 22 months (range, 12-36 month). The average Constant score improved from 49 points (range, 35-57 points) to 81 points (range, 75-86 points). The average satisfaction score improved from 4.5 of 10 (range, 2-6) to 8.5 of 10 (range 7-9). All patients made a good clinical recovery at 3 to 6 months after surgery. At the last follow-up, full radiographic union was observed in 6 patients, partial union in 1 patient, and persistent radiologic nonunion in 1 patient. Anterior bulging of the absorbable screws was noted in 2 patients, and the screws were trimmed 6 months after the first procedure.

CONCLUSIONS

We have found that this new arthroscopic technique of fixation of os acromiale with absorbable screws provides promising clinical, cosmetic, and radiologic results with high patient satisfaction.

Pattern and time phase of shoulder function and power recovery after arthroscopic rotator cuff repair

BACKGROUND

It has been our observation that early during rehabilitation after rotator cuff repair, patients may take a step back before improving. The purpose of this study is to investigate the pattern and time phase of changes in Constant score and strength recovery after arthroscopic rotator cuff repair.

MATERIALS AND METHODS

Forty-five patients undergoing arthroscopic rotator cuff repair were prospectively enrolled in this study. Patients underwent scoring preoperatively with the Constant score. All were followed up at 3 months and 6 months after surgery. The Constant score and strength at 3 months were compared with those at the 6-month mark.

RESULTS

The mean Constant score improved from 46.4 points (SD, 17.3) preoperatively to 51.8 points (SD, 13.5) 3 months postoperatively (P = .0777). At 6 months postoperatively, the mean Constant score was 69.0 points (SD, 11.1), a significant increase from both the preoperative (P < .0001) and 3-month (P < .0001) results. The mean preoperative strength result of 4.5 kg (SD, 3.2) decreased significantly to 3.3 kg (SD, 1.8) at 3 months postoperatively (P = .0154) before improving to 5.8 kg (SD, 2.6) at 6 months postoperatively. The improvement in strength at 6 months was significant compared with both the preoperative (P = .0070) and 3-month (P < .0001) results.

CONCLUSIONS

Although there is highly significant improvement in overall function (Constant score) and strength 6 months postoperatively, patients appear to take a step back before improving, in fact with a drop in strength at 3 months. This may cause concern in patients and may require assurance that time and effort with physiotherapy will improve function and symptoms.

Arthroscopic management of the painful snapping scapula

PURPOSE

The aim of this study was to evaluate the results of the arthroscopic management of the snapping scapula syndrome.

TYPE OF STUDY

Case series.

METHODS

Thirteen patients underwent surgery for painful scapular snapping that had not responded to adequate conservative treatment. They had no evidence of anatomic abnormalities on plain radiographs. All patients underwent bursectomy and resection of bands of fibrous tissue at the superomedial angle. Bone was resected from the superomedial angle only if it appeared to be prominent during arthroscopy. This occurred in 3 cases. The patients' outcomes were assessed subjectively by their ability to return to work and their return to leisure, as well as the Constant score.

RESULTS

At the time of follow-up, 9 patients (69%) reported an improvement in their symptoms. Their median Constant score was 87 (range, 95 to 58). Four patients felt that their symptoms were unchanged or worse. Their median Constant score was 55 (range, 66 to 32). Of 9 employed patients, 8 returned to their previous careers. This group included 2 patients with physically demanding jobs. Of 9 patients who played sports regularly, 6 returned to their presymptomatic level of sporting activity. There were no complications.

CONCLUSIONS

Subscapular bursectomy is a safe procedure with a low rate of morbidity. In the absence of a definable anatomic abnormality, arthroscopic bursectomy for the painful snapping scapula can result in satisfactory outcomes in approximately 70% of patients. More clearly defined indications for and contraindications against surgery are required to avoid poor results. Complete resolution of the snapping in the subscapular bursa is not necessary to obtain a satisfactory result.

LEVEL OF EVIDENCE

Level IV, case series, no control group.

Practice parameters for sublingual immunotherapy

The efficacy and safety of sublingual immunotherapy (SLIT) are currently supported by clinical trials, meta-analysis and post-marketing surveys. Practice parameters for clinical use of SLIT are proposed here by a panel of Italian specialists, with reference to evidence based criteria. Indications to SLIT include allergic rhinoconjunctivitis, asthma, and isolated conjunctivitis (strength of recommendation: grade A). As to severity of the disease, SLIT is indicated in moderate/severe intermittent rhinitis, persistent rhinitis and mild to moderate asthma (grade D). SLIT may be safely prescribed also in children aged three to five years (grade B), and its use in subjects aged more than 60 years is not prevented when the indications and contraindication are ascertained (grade D). The choice of the allergen to be employed for SLIT should be made in accordance with the combination of clinical history and results of skin prick tests (grade D). Polysensitisation, i.e. the occurrence of multiple positive response does not exclude SLIT, which may be done with the clinically most important allergens (grade D). As to practical administration, co-seasonal, pre co-seasonal, and continuous schedules are available, being the latter recommended for perennial allergens or for pollens with particularly prolonged pollination, such as Parietaria (grade D). For pollens with relatively short pollination, such as grasses and trees (cypress, birch, alder, hazelnut, olive) the pre co-seasonal and perennial schedules are preferred (grade C). The build-up phases suggested by manufacturers can be safely used (grade A), but they can be modified according to the patient's tolerance (grade C). A duration of SLIT of 3-5 years is recommended to ensure a long-lasting clinical effect after the treatment has been terminated (grade C).

Geometrical analysis of Copeland surface replacement shoulder arthroplasty in relation to normal anatomy

This study examines the effect of humeral head surface replacement on the geometry of the arthritic glenohumeral joint and correlates changes to clinical outcome. Thirty-nine patients undergoing resurfacing arthroplasty were prospectively followed up clinically and radiologically for a mean of 38 months (range, 24 to 72 months). Measurements were taken from coronal radiographs by use of a validated technique. There was an estimated mean 6 mm erosion of preoperative lateral offset (coracoid base to greater tuberosity). The prosthesis reduced the humeral head radius by a mean of 3.5%. Humeral offset (greater tuberosity to center of instant rotation) increased by a mean of 5 mm (95% CI, 3.8 to 6.4; P<.01). Mean age-/sex-adjusted Constant scores improved from 26 to 83 points (P<.01). The improved postoperative motion showed a nonlinear relationship with humeral offset. We conclude that surface replacement restores humeral offset and the lever arm of the deltoid and supraspinatus while otherwise mimicking individual anatomy. Function depends on adequate restoration of this lever arm without overstuffing the joint.

Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis

BACKGROUND

Shoulder arthroplasty with a stemmed prosthesis is a recognized treatment for rheumatoid arthritis of the shoulder. The humeral component of the Copeland cementless surface replacement arthroplasty consists of a cup for surface replacement with a short central peg for primary fixation to the bone. We hypothesized that surface replacement may offer some advantages over stemmed prostheses.

METHODS

Between 1986 and 1998, seventy-five shoulders underwent surface replacement arthroplasty (thirty-three hemiarthroplasties and forty-two total shoulder arthroplasties) for the treatment of rheumatoid arthritis. The results of these procedures were reviewed after an average duration of follow-up of 6.5 years. Patients were assessed with use of the Constant score, a patient satisfaction score, and radiographs.

RESULTS

The average Constant score was 47.9 points (age and sex-adjusted score, 71%) in the hemiarthroplasty group and 53.4 points (age and sex-adjusted score, 76%) in the total shoulder replacement group. The mean range of active flexion improved from 50 degrees in the hemiarthroplasty group and 47 degrees in the total shoulder replacement group to 101 degrees and 104 degrees, respectively. Seventy-two of the seventy-five shoulders were considered by the patients to be much better or better at the time of the review. Of the sixty-eight humeral implants that were evaluated radiographically, fifty-six (82%) showed no lucencies, eleven (16%) showed localized lucencies of <1 mm in width, and one was definitely loose. Of the thirty-nine glenoid implants that were evaluated radiographically, nineteen (49%) showed no lucencies, nineteen showed localized lucencies of <1 mm, and one was definitely loose. No lucencies were observed adjacent to the hydroxyapatite-coated implants. Thirty-nine (57%) of the sixty-eight shoulders showed some degree of superior subluxation. Three patients required a major reoperation: two required a revision because of loosening of both components, and one patient with pain at the site of a hemiarthroplasty had a revision to a total shoulder arthroplasty to provide relief.

CONCLUSIONS

The indications for this surface replacement are the same as those for the conventional stemmed prostheses, but the surface replacement has the advantage of bone preservation as well as avoidance of the potential complications associated with a long humeral stem in rheumatoid bone. This procedure is not suitable for severely damaged joints in which the humeral head is insufficient or too soft.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

The role of arthroscopy for the problem shoulder arthroplasty

Between 1995 and 2000, 29 patients who had excessive pain or limitation of motion after a shoulder arthroplasty underwent arthroscopy. Preoperative diagnoses of impingement syndrome in 10 patients (treated by arthroscopic subacromial decompression), large rotator cuff tear in 1, loose bodies in 1, unstable cuff arthropathy in 1, and septic arthritis in another were confirmed at arthroscopy. Of the 15 patients without a preoperative diagnosis, 7 had postarthroplasty capsular fibrosis, with 6 undergoing arthroscopic capsular release. A malpositioned glenoid component was found in 1 patient. Loose or worn components were found in 4 of the shoulders, impingement with a small partial-thickness cuff tear was identified in 1, a florid synovitis was present in another, and in 1 no abnormality could be found. The procedures were often hindered by limited access and reflection from the prosthesis. Arthroscopy after shoulder arthroplasty is useful for the diagnosis and treatment of pain and loss of motion in selected patients but can be technically challenging.

Reossification and fusion across the acromioclavicular joint after arthroscopic acromioplasty and distal clavicle resection

Arthroscopic acromioplasty and distal clavicle resection has now become an accepted method of treatment for acromioclavicular (AC) joint arthritis. Complications following arthroscopic acromioplasty are relatively uncommon and include instrument breakage, hematoma, traction neuropathy, infection, acromial fracture, reflex sympathetic dystrophy, and recurrence of symptoms. Although heterotopic ossification within the soft tissues has also been reported, complete reossification of the resected clavicle has not. We report a case of reossification of the clavicle and fusion across the AC joint following arthroscopic acromioplasty and distal clavicle resection.

Thermal capsular shrinkage for shoulder instability

We present the short- and medium-term clinical results of thermal shrinkage in selected groups of patients with multidirectional or capsular stretch-type instability. We treated 56 patients (61 shoulders) by laser-assisted capsular shrinkage (LACS) and 34 patients (38 shoulders) by radiofrequency (RF) capsular shrinkage. The two groups were followed for mean periods of 40 months and 23 months, respectively.

In the LACS group the mean Walch-Duplay score improved to 90 points 18 months after the operation, but then declined to a plateau of about 80 points; 59% of patients considered their shoulders to be ‘much better’ or ‘better’ but there was a failure rate of 36.1%. For the RF group the mean Walch-Duplay and Constant scores were 80 points at the various follow-up times; 76.3% of patients considered their shoulder to be ‘much better’ or ‘better’. RF failed in nine shoulders (23.7%). These results match some clinical series of patients with multidirectional instability, undergoing open inferior capsular shift, with a similar rate of failure. We believe that the minimal morbidity involved makes thermal shrinkage a viable alternative to open capsular shift in this difficult group of patients.

Thermal capsular shrinkage for shoulder instability. Mid-term longitudinal outcome study

We present the short- and medium-term clinical results of thermal shrinkage in selected groups of patients with multidirectional or capsular stretch-type instability. We treated 56 patients (61 shoulders) by laser-assisted capsular shrinkage (LACS) and 34 patients (38 shoulders) by radiofrequency (RF) capsular shrinkage. The two groups were followed for mean periods of 40 months and 23 months, respectively. In the LACS group the mean Walch-Duplay score improved to 90 points 18 months after the operation, but then declined to a plateau of about 80 points; 59% of patients considered their shoulders to be 'much better' or 'better' but there was a failure rate of 36.1%. For the RF group the mean Walch-Duplay and Constant scores were 80 points at the various follow-up times; 76.3% of patients considered their shoulder to be 'much better' or 'better'. RF failed in nine shoulders (23.7%). These results match some clinical series of patients with multidirectional instability, undergoing open inferior capsular shift, with a similar rate of failure. We believe that the minimal morbidity involved makes thermal shrinkage a viable alternative to open capsular shift in this difficult group of patients.

Atraumatic shoulder instability. Discussion of classification and results after capsular imbrication

This study consists of 27 shoulders in 24 patients whose atraumatic shoulder instability was treated with the imbrication procedure described by Rockwood. Follow-up after 2 years or more showed the following results: 37% excellent, 30% good, 15% fair and 18% poor (Rowe score). No statistically significant differences in the results were observed between the dominant and non-dominant arm, nor in post-operative return to sports activities. Those with voluntary instability had more laxity at follow-up and tended to have poorer results. Those with unidirectional laxity had only good or excellent results and showed no post-operative laxity. We found no other reliable indication of the results of surgery. The difficulties of classifying shoulder instability by such factors as trauma, laxity and direction of instability are discussed. Overall, we consider capsular imbrication to be a good treatment for involuntary atraumatic shoulder instability.

[Alcohol consumption and coronary disease in men]

It has been recently suggested by many epidemiological studies, and emphasized by a nonspecialistic press, that a moderate alcohol intake may exert a protective role in coronary heart diseases. In our study, by means of a questionnaire, the consumption of alcohol in 100 male patients, less than 70 years old, affected by myocardial infarction and/ or angina pectoris, has been evaluated during a period before and after the admission to our Coronary Care Unit. On the basis of their alcohol intake, patients were divided into five categories: abstainers (8%), daily intake lower than one drink (7%), between one and two drinks (8%) between three and four drinks (46%) and equal or higher than five drinks (31%). In the light of these results, we suggested that, in our region (a country area in the north-east of Italy), there are higher levels of ethanol intake compared to those reported by other authors, that these parameters are only slightly modified by the occurrence of coronary heart diseases and that alcohol consumption, although low and moderate, must be therefore emphasized with extreme caution.

[Colchicine in the treatment of idiopathic recurrent pericarditis. Report of a case]

Treatment of recurrence, which is one of the major complications of pericarditis, is often difficult. After three recurrences of idiopathic acute pericarditis, over a period of four months, despite therapy with acetylsalicylic acid, indomethacin and methilprednisolone, a patient, 37 years old, responded favorably to colchine treatment. No recurrences, no side effects were observed, after a prolonged low dose treatment. Our report suggests, therefore, that colchinine may be beneficial in acute attacks of idiopathic pericarditis and may be useful in avoiding recurrent episodes of pericarditis.

[Pharmacodynamics and pharmacokinetics of flecainide in cardiac pre-excitation of the bundle of Kent]

In order to identify the flecainide plasma concentrations capable to inhibit the abnormal Kent's pathways, 9 patients affected by a Wolff-Parkinson-White syndrome were studied. One of them (a female 21 years old) previously received 200 mg oral flecainide "una tantum", 8 received 100 mg bid for at least 2 weeks. They had a short PR interval and an evident delta wave on the surface ECG, diagnostic for pre-excitation syndrome. The flecainide plasma half-life calculated in 6 patients chronically treated correlated directly and strictly with age. In all patients the flecainide treatment blocked the conduction through the bundle of Kent (normal PR, no delta wave), then the treatment was stopped and the elimination kinetics of flecainide were studied while a Holter 24h ECG monitoring was performed; thus we could extrapolate the flecainide plasma concentrations at which, during the elimination phase, the PR interval became short and the delta wave reappeared. Since short PR and delta wave are the expression of pre-excitation, we were able to determine the minimum concentrations capable to inhibit conduction through the abnormal bundles (290.0 ng ml-1 in the acutely treated patient and average 275.0 ng ml-1 in the chronically treated patients). These plasma levels are near to the lower therapeutic range accepted for ventricular ectopic arrhythmias (200 divided by 800 ng ml-1). Only larger studies will indicate if a relationship exists between the blockade of abnormal pathways and the preventive effect of flecainide on arrhythmias of Wolff-Parkinson-White syndrome. Another open question is whether a simple, non-invasive pharmacodynamic and pharmacokinetic procedure like that one described in the present paper can be used to predict the efficacy of treatment in patients with cardiac pre-excitation.