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We highlighted the important factors to consider when counselling patients with non-traumatic rotator cuff tears on which route to take. Factors include the clinical outcomes of surgical and non-surgical

routes, tendon healing rates with surgery (radiological outcome) and natural history of the tears if treated non-operatively.

METHODS A PRISMA-compliant search was carried out, including the online databases PubMed and EMBASE from 1960 to the end of June 2018. FINDINGS A total of 49 of the 743 (579 PubMed and 164 EMBASE) results yielded by the preliminary search were included in the review. There is no doubt that the non-surgical route with an appropriate physiotherapy programme has a role in the management of degenerative rotator cuff tears. This is especially the case in patients with significant risk factors for surgery, those who do not wish to go through a surgical treatment and those with small, partial and irreparable tears. However, rotator cuff repair has a good clinical outcome with significant improvements in pain, range of motion, strength, quality of life and sleep patterns.

Methods: From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. TypeAhemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed.

 

Results: After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8).

 

Conclusions: TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.

Background

The clinical trial aimed to prospectively compare the functional outcome of patients undergoing arthroscopic rotator cuff repair using Transosseous-Equivalent Double-Row (TEDR) or single-raw (SR) suture anchor techniques at three years postoperatively for both large (over 3cm) and small (under 3cm) tears.

Methods

Eighty patients with a symptomatic and MRI proven full-thickness RC tear, who had failed conservative management of at least 6 months duration and who had a complete passive range of motion of the affected shoulder were enrolled in the trial. Patients were randomized to TEDR repair (n=40) or SR repair (n=40). Subgroup analysis was conducted for tears < 3 cm (TEDR n = 17, SR n=19) and tears > 3 cm (TEDR n=23, SR n=21). Primary outcomes included the Oxford Shoulder Score (OSS), the University of California, Los Angeles score (UCLA), and the Constant-Murley Outcome Score (CMS). The secondary outcomes included a 0-100 mm Visual Analogue Scale (VAS) for pain, range of motion (ROM) and EQ-5D. 

Results

There was a significant difference in the mean OSS postoperative score for tears >3cm (p=0.01) and mean improvement from baseline in the TEDR group (p=0.001). For tears >3cm, mean postoperative scores were also significantly higher in the TEDR group for UCLA (p=0.015) and CMS (p=0.001). Post Hoc testing showed that the differences between these groups was statistically significant (p<0.05). For tears <3cm, a significant postoperative difference in favor of SR repair was seen with mean CMS (p=0.011), and post hoc testing showed that the difference was statistically significant (p=0.015). No significant difference was seen with mean postoperative OSS or UCLA and post hoc testing did not show a statistically significant difference between groups.

 

Conclusions

TEDR repair showed improved functional outcomes for tears greater than 3cm when compared to SR repair. For tears less than 3cm, no clear benefit was seen with either technique.

Level of evidence: Level I; Randomized Controlled Trial; Treatment Study

Despite the vast improvement in techniques for arthroscopic rotator cuff surgery, repairs of massive and large tears remain an issue as they are associated with significantly high failure rates, particularly in the elderly population. As a result, there has been a focus of attention to improve rotator cuff repair healing rates. One of the strategies is augmentation of the repair with a patch. Arthroscopic augmentation is, however, technically demanding with challenges in introduction and stabilization of the patch. The purpose of this Technical Note is to describe a technique for arthroscopic rotator cuff repair with augmentation, which offers additional advantages over previous techniques because it facilitates the passage of the patch as well as providing a more robust medial stabilization of the augment and therefore possibly a stronger construct.

Methods: From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. TypeAhemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed.

 

Results: After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8).

 

Conclusions: TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.

We perform a standardised routine when testing for implant stability. No single test is perfectly accurate and by combining tests even subtle instability can be recognised more readily. Prior to performing these tests we either remove or relax any self retainers, which may introduce a false-negative and instead use a hand-held retractor to visualise the joint. We start by assessing the range of motion and in particular looking for hinged opening of the joint during external rotation. Stability is also tested with the arm in a position of extreme external rotation and abduction, followed by testing in extreme internal rotation and flexion. Further testing includes the ‘shuck test’ involving traction along the longitudinal axis of the humerus to assess for pistoning and checking the resting tension within the conjoint tendon.

We then proceed to the “Bed Shuffle Test” bringing the shoulder into adduction and extension with the application of a proximally directed force along the humeral shaft to try and dislocate the prosthesis antero-superiorly (Fig. 1). This is an effort to recreate the action when the patient is shuffling themselves up the bed whilst weight bearing via the elbow. We then perform the Lateral Thrust Test with the arm in line with the torso and the shoulder in neutral rotation. The index finger is placed on the medial aspect of the proximal humerus and a force applied laterally to displace the proximal humerus off the glenosphere. The ability to dislocate the reverse prosthesis using a laterally directed force indicates inadequate mediolateral offset. If any alterations are made to the construct, we simply repeat the full gamut of tests until optimal stability is achieved.

Questions/Purpose (1) What is the likelihood of infection control after two-stage revision using an antibiotic cement spacer for patients with PJI of the shoulder?

(2) What are the improvements in Constant and Murley scores at 2 years after these staged revisions?

 Between 2000 and 2013, we treated 48 patients with PJI of the shoulder using two-stage revision including an antibiotic-containing cement spacer during the first stage. Of those, 38 (79%) were available for review at a minimum of 24 months (mean, 52 6 34 months). During the first stage, removal of the prosthesis, d´ebridement, and implantation of a gentamicin and vancomycin-filled cement spacer were performed by four different surgeons followed by antibiotic therapy (2 weeks intravenous plus 10 weeks oral). For the second stage, we generally tried a reverse total shoulder arthroplasty (RTSA; n = 26). In case of severe glenoid destruction, hemiarthroplasty (HA; n = 8) was used as a salvage option. In 14 patients the cement spacer was left in place because the patients refused further surgery or were not operable owing to medical reasons. 

 

Results Successful infection control was achieved in 36 of 38 patients (95%). Patients who underwent treatment with a cement spacer had increased Constant and Murley scores at latest followup compared with their pretreatment scores. For patients who underwent staged treatment followed by second-stage RTSA (n = 23), the Constant and Murley scores increased. The Constant and Murley scores did not improve in

patients who underwent HA  or who retained the spacer 

Conclusion Revision arthroplasty using an antibiotic loaded cement spacer provided successful infection control in patients with periprosthetic shoulder infections in this small, retrospective series. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after HA and cement spacer; however, baseline differences among patient groups very likely contributed to these differences, and they should not be attributed to implant selection alone.

What do patients expect of rotator cuff repair and does it matter?

 

The purpose of this study was to evaluate what patients expect from rotator cuff repair, the extent of fulfilment of preoperative expectations and to determine the relationship between expectations and Patient-reported outcome measures (PROMs) before and after surgery.

 

80 patients were surveyed prior to rotator cuff repair using the Hospital for Special Surgery Shoulder Surgery Expectations Survey, Oxford Shoulder Score (OSS) and Euroqol EQ5D. At 6 months and 2 years after surgery, patients completed a modified Shoulder Surgery Expectations Fulfilment Survey, OSS, EQ5D and satisfaction survey (0-100%). Preoperative and postoperative PROMs data were compared with paired t-tests. The relationship between preoperative expectations, postoperative expectations fulfilment and PROMs were examined using multiple logistic regression.

 

OSS improved from a preoperative mean of 24.5 to 43.2 at 2 years (P<0.01); EQ5D improved from 0.47 preoperatively to 0.90 at final follow-up (P<0.01). Median postoperative satisfaction was 90%. Preoperatively over 80% of patients rated 8 of 17 expectations as “very” or “somewhat” important; at 6 months 5 of 8 important expectations and at 2 years all 8 important expectations were rated as fulfilled by over 80% of patients. The expectations of “relief of daytime and night-time pain”,

“the shoulder to be the way it was before” and “improve range of movements” were ranked the highest prior to surgery. Patients’ preoperative expectations were not correlated with age, gender or preoperative PROMS nor did they predict postoperative PROMS. There was a statistically significant correlation between fulfilment of expectations after surgery and patient satisfaction.

Conclusions: Patients whose expectations of surgery are fulfilled achieve a high degree of satisfaction after rotator cuff repair. Patients may be reassured that surgery is successful in fulfilling expectations that are rated as important but it may take up to 2 years for these expectations to be met.

Purpose: The indication for operative treatment of displaced midshaft clavicle fractures remains con-troversial. However, if plate fixation is considered, implant prominence and skin irritation are the mostcommon causes for re-operation. Low profile implants as well as closely contouring plates to the individ-ual anatomy may reduce these complications. The aim of this study was to compare the fitting accuracyand implant prominence of 3.5 mm pelvic reconstruction plates (PRP) with pre-contoured anatomicalclavicle plates (PACP) for midshaft clavicle fractures.

 

Methods: Three-dimensional data of the largest, median and smallest male and female clavicle of anexisting database of 89 cadaveric clavicles were included for analysis. A three-dimensional model of acommercially available PACP was used for digitally positioning of the plate on the segmented clavicles.Three-dimensional printouts of each clavicle were produced and the 3.5 mm reconstruction plates weremanually bent and positioned by the senior author. Computed tomography scans and three-dimensionalreconstructions were then obtained to digitally compare the fitting accuracy and implant prominence.

 

Results: Pelvic reconstruction plates offered superior fitting accuracy and lower implant prominencecompared to PACP. The largest difference in implant prominence was observed in large sized femaleclavicles and measured 3.6 mm.Conclusion: Both, the less costly PRP plates and commercially available PACP for midshaft fractures of theclavicle demonstrated a clinically acceptable fitting accuracy. The manually bent pelvic-reconstructionplates demonstrated reduced implant prominence with superior fitting. Hypothetically this might con-tribute to a reduced rate of reoperation.Level of evidence: Level IV cadaveric study.

Subpectoral long head of the biceps tenodesis is gaining popularity as a technique for treating patients with various pathologies of the tendon or its anchor to the superior labrum. It has the added advantage of addressing bicipital groove pathologies. Various techniques for performing it have been described, but none is without problems. We present a modification of the previously described techniques that involves 2 all-suture anchors and offers the added advantage of a reduced risk of fracture without sacrificing the biomechanical strength of the construct. We also believe that it may potentiate healing by providing an adequate surface contact area between the tendon and bone with a minimal risk of damage to the tendon and neurovascular structures.

Accurate measurement of the glenoid version is important in performing total shoulder arthroplasty (TSA). Our aim was to evaluate the Ellipse method, which involves formally defining the vertical mid-point of the glenoid prior to measuring the glenoid version and comparing it with the ‘classic’ Friedman method.

 

Methods

This was a retrospective study which evaluated 100 CT scans for patients who underwent a primary TSA. The glenoid version was measured using the Friedman and Ellipse methods by two senior observers. Statistical analyses were performed using the paired t-test for significance and the Bland-Altman plot for agreement.

 

Results

The mean glenoid version was -3.11° (-23.8° to 17.9°) using the Friedman method and -1.95° (-29.8° to 24.6°) using the Ellipse method (p = 0.002). In 16 patients the difference between methods was greater than 5°, which we considered to be clinically significant. There was poor agreement between methods with relatively large 95% limits of agreement. There was excellent inter-rater agreement between the observers for the Ellipse method and similarly, the intrarater agreement was excellent with a repeatability coefficient of 0.94.

 

Conclusion

We recommend the use of the Ellipse modification to define the mid glenoid point prior to

measuring the glenoid version in patients undergoing TSA.

The transosseous-equivalent cross-bridge double row (TESBDR) rotator cuff (RC) repair

the technique has been developed to optimize healing biology at a repaired RC tendon insertion. It has been shown in the laboratory to improve the pressurized contact area and mean footprint pressure when compared with a double row anchor technique. Pressure has been shown to influence healing between tendon and bone, and the tendon compression vector provided by the transosseous-equivalent suture bridges may enhance healing. The purpose was to prospectively evaluate the outcomes of arthroscopic TESBDR RC repair.

 

Methods: Single-centre prospective case series study. Sixty-nine patients were selected to undergo arthroscopic TESBDR RC repair and were included in the current study. Primary outcome measures included the Oxford Shoulder Score (OSS), the University of California, Los Angeles (UCLA) score, the Constant-Murley (CM) Score and Range of motion (ROM). Secondary outcome measures included a Visual Analogue Scale (VAS) for pain, another VAS for patient satisfaction from the operative procedure, EuroQoL 5-Dimensions Questionnaire (EQ-5D) for quality of life assessment.

Results: At 24 months post-operative, average OSS score was 44, average UCLA score was 31, average CM score was 88, average forward flexion was 145, average internal rotation was 35, average external rotation was 79, average abduction was 150, average EQ-5D score was 0.73, average VAS for pain was 2.3, and average VAS for patient satisfaction was 9.2.

Conclusion: Arthroscopic TESBDR RC repair is a procedure with good post-operative functional outcome and low re-tear rate based on a short term follow-up.

Sternoclavicular joint (SCJ) injuries represent 5% of all injuries to the shoulder complex and are categorized into anterior (more common) and posterior dislocations.

Treatment options range from non-operative treatment to various operative options; these include

closed reduction with variable outcomes. Thus, studies proclaim inferior outcomes and support a low threshold for open reduction.

A proportion of SCJ dislocations develop chronic instability and they usually present with discomfort and restriction of activities with frank instability being less common; that is why symptomatic injuries necessitate reconstruction using various methods.

We describe our unicortical double ligament technique to manage unstable

SCJ injuries. We report a safe and effective technique for the reconstruction of anterior SC joint dislocations, employing a synthetic graft using a unicortical technique with minimal dissection anterior to the joint.

The treatment of periprosthetic joint infection (PJI) of the shoulder with two-stage revision arthroplasty

using an antibiotic-loaded cement spacer is established strategy, but there is sparse information regarding the likelihood of infection control and restoration of the shoulder.

 

(1) What is the likelihood of infection control after two-stage revision using an antibiotic cement spacer for patients with PJI of the shoulder?

(2) What are the improvements in Constant and Murley scores at 2 years after these staged revisions?

 

Patients and Methods: Between 2000 and 2013, we treated 48 patients with PJI of the shoulder using two-stage revision including an antibiotic-containing cement spacer during the first stage. Of those, 38 (79%) were available for review at a minimum of 24 months (mean, 52 6 34 months). Ten patients (21%) were excluded because they were deceased (n = 3), moved abroad (n = 4), or refused follow-up (n = 3), leaving 38 for analysis in this retrospective study.

During the first stage, removal of the prosthesis, debridement, and implantation of gentamicin and vancomycin-filled cement spacer were performed by four different surgeons followed by antibiotic therapy (2 weeks intravenous plus 10 weeks oral).

For the second stage, we generally tried a reverse total shoulder arthroplasty (RTSA; n = 26). In case of severe glenoid destruction, hemiarthroplasty (HA; n = 8) was used as a salvage option. In 14 patients the cement spacer was left in place because the patients refused further surgery or were not operable owing to medical reasons. The primary outcome included the proportion of patients achieving infection control 2 years after the second-stage procedure after implantation of the cement spacer.

 

Infection control was determined as the absence of the Musculoskeletal Infection Society PJI criteria.

The clinical outcome assessed with the Constant and Murley scores served as the secondary outcome parameter. A subgroup (RTSA; HA, spacer retention) analysis of the Constant and Murley scores was performed. Successful infection control was achieved in 36 of 38 patients (95%). Patients who underwent treatment with a cement spacer had increased Constant and Murley scores. latest follow-up compared with their pretreatment scores. For patients who underwent staged treatment followed by second-stage RTSA (n = 23), the Constant and Murley scores increased. The Constant and Murley scores did not improve in patients who underwent HA or who retained the spacer

 

Conclusion Revision arthroplasty using an antibiotic-loaded cement spacer provided successful infection control

in patients with periprosthetic shoulder infections in this small, retrospective series. Functional improvement

was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after HA and cement

spacer; however, baseline differences among patient groups very likely contributed to these differences, and

they should not be attributed to implant selection alone. 

The purpose of this paper was to determine whether acromial morphology influences anteroposterior shoulder stability. We hypothesized that a more horizontal and higher position of the acromion in the sagittal plane would be associated with posterior instability.

In this retrospective study, patients with unidirectional posterior instability were age and sex-matched to a cohort of patients with unidirectional anterior instability. Both cohorts were compared with a control group of patients with no instability and no degenerative glenohumeral (rotator cuff and/or joint surface) or acromial changes. Measurements on radiographs included posterior acromial tilt, anterior and posterior acromial coverage (AAC and PAC), posterior acromial height (PAH), and the critical shoulder angle (CSA).

The number of patients enrolled in each instability group was 41, based on a priori power analysis. The control group consisted of 53 shoulders. Of the measured anatomic factors, PAH showed the most significant association with posterior instability (odds ratio [OR] = 1.8; p < 0.001) in the logistic regression model. PAH was significantly greater in the posterior instability group compared with the anterior instability group (30.9 versus 19.5 mm; p < 0.001). With a cutoff value of PAH of 23 mm, the OR for posterior instability was 39. Shoulders with posterior instability were also significantly

different from normal shoulders with regard to PAH (p < 0.001), AAC (p < 0.001), and PAC (p < 0.001) whereas, in the shoulders with anterior instability, all of these values except the AAC (p = 0.011) did not differ from those of normal shoulders.

Specific acromial morphology is significantly associated with the direction of glenohumeral instability. In shoulders with posterior instability, the acromion is situated higher and is oriented more horizontally in the sagittal plane than in normal shoulders and those with anterior instability; this acromial position may provide less osseous restraint against posterior humeral head translation. A steep “Swiss chalet roof-type” acromion virtually excluded recurrent posterior instability in an albeit relatively small cohort of patients. Additional investigation is needed to determine the

relevance of these findings for future treatment.

Distal triceps rupture is an uncommon but debilitating injury, and surgical fixation is almost invariably

warranted. A number of techniques have been described in the literature in which combinations of transosseous tunnels and bone anchors have been used. We describe a modification to existing techniques the triceps pulley-pullover technique with all-suture anchors. This technique minimizes bone loss while maximizing the bone-tendon contact area and creating a double-row repair to optimize strength and healing.

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