Introduction: Shoulder hemiarthroplasty is an established treatment for complex proximal humeral fractures but the functional results of these hemiarthroplasties in proximal humeral fractures are often poor and unpredictable. The capacity of restoring proximal humeral anatomy in such these complex fractures is of capital importance to obtain proper placement and secure fixation of the tuberosities to the prosthesis. The purpose of this study was to determine the value of the upper edge of the pectoralis major insertion as a landmark to determine proper height and version of hemiarthroplasties implanted for proximal humeral fractures. Material and Methods: The upper edge of the pectoralis major insertion was referenced with a metallic device in 20 cadaveric humerus. A Computed Tomography study was performed in all the specimens. Total humeral length was recorded in all the specimens. The distance between the upper pectoralis major insertion and the tangent to the humeral head was also recorded. The anatomical neck of the humeral head was determined in the axial plane of the CT scan and a perpendicular line was drawn to represent the posterior fin of the prosthesis. To that image, the CT scan slice showing the upper insertion of the pectoralis major was superimposed and the distance of the metallic reference to the posterior fin of the prosthesis was recorded as it was the angle formed by the line connecting the upper pectoralis major insertion with the center of the anatomical neck diameter and with the posterior fin of the prosthesis. Qualitative variables are presented in absolute and percentage values. Quantitative variables are presented with mean values and standard deviation. Results: Mean total humeral length was 32,13 cm. The mean distance from the upper pectoralis major insertion to the tangent to the humeral head was of 5,64. The mean distance from the upper pectoralis major insertion to the tangent to the humeral head represents the 17,55% of the total humeral length. The mean distance of the upper pectoralis major insertion to the posterior fin of the prosthesis was of 1,06 cm. The angle between the upper pectoralis major insertion and the posterior fin of the prosthesis was of 24,65º. Conclusions: Mean distance from the upper part of the pectoralis major insertion to the top of the humeral head of 5, 6 cm with a 95% confidence interval. Placement of the prosthesis in the proper retroversion can be achieved by placing the posterior fin 1,06 cm posterior to the upper insertion of the pectoralis major or by placing the posterior fin at 24,65º with respect to the upper insertion line. Upper insertion of the pectoralis major constitutes a reliable reference to reproduce anatomy in hemiarthroplasties for proximal humeral fractures

Sternoclavicular joint infections are uncommon but severe and complex condition usually in medically complex and compromised hosts. These infections are challenging to treat with risks of infection extending into the mediastinal structures and surgical drainage is often faced with problems of multiple unplanned returns to theatre, chronic non-healing wounds that turn into sinus and the risk of significant clinical escalation and death. Percutaneous aspirations or small incision drainage often provide inadequate drainage and failed control of infection, while open drainage and washout require multidisciplinary support, due to the close proximity of the mediastinal structures and the great vessels as well as failure to heal the wounds and creation of chronic wound or sinus. We present our series of 8 cases over 6 years where we used the plan of open debridement of the Sternoclavicular joint with medial end of clavicle excision to allow adequate drainage. The surgical incision was not closed primarily, and a suction vacuum dressing was applied until the infection was contained on clinical and laboratory parameters. After the infection was deemed contained, the surgical incision was closed by local muscle flap by transferring the medial upper sternal head of the Pectoralis Major muscle to fill in the sternoclavicular joint defect. This technique provided a consistent and reliable way to overcome the infection and have the wound definitively closed that required no secondary procedures after the flap surgery and no recurrence of infections so far. We suggest that open and adequate drainage of Sternoclavicular joint staged with vacuum dressing followed by pectoralis major local flap is a reliable technique for achieving control of infection and wound closure for these challenging infections

Introduction: Between June 2005 and September 2007, ten male athletes underwent repair of the pectoralis major tendon using a new double row surgical technique whereby employing three bone anchors to produce a large foot print of the pectoralis major tendon. Here, we present our new surgical technique for the repair of the pectoralis major tendon with the results. Patients: The mean age was 33.9 years (23–46 years) and the average follow up was 20.3 months (12–39). The mean time between surgery and the original injury was 11.6 weeks (1–48 weeks). We used the visual analogue scale for determining the level of satisfaction with regards to cosmesis and pain. Also, the patients were asked them about their subjective loss of strength. Results: Eight patients were in pain prior to surgery and all patients were unsatisfied with the appearance of their chest. The average loss of strength was 75% pre-operatively. At the final follow up, none of the patients complained of any pain while pushing things away from their body; nine patients had no pain on moving their arm across the chest whilst one patient reported mild pain. Nine were satisfied with the appearance and the average regain in strength was around 90%. One patient developed a deep infection requiring a further washout and antibiotics. No re-rupture was seen amongst our patients. Hence, we conclude that satisfactory results can be achieved with this new technique

Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over fifty percent of these injuries occur in athletes classically in weight-lifters during bench press. In this study, thirteen cases of distal rupture of the pectoralis major muscle in athletes are presented. All patients underwent surgical repair. Physical findings and surgical technique are described. Magnetic resonance imaging was used in the diagnosis of all patients and intra-operative findings correlated with the reported scans in eleven patients with minor differences in two patients. During follow up examination, six patients had excellent results, six had good results and one had a fair result. Eleven patients could return to sports activity at their preoperative level. Among our patients we emphasize that of an orthopaedic resident who suffered a rupture of his pectoralis major tendon as an unusual complication of closed manipulation of an anterior shoulder dislocation. According to the literature and our experience, we suggest that only surgical repair of the pectoralis major rupture will result in complete recovery and restoration of the full strength of the muscle which is essential for the active athlete

Introduction and Aims: Pectoralis major tendon rupture is a relatively rare injury, resulting from violent, eccentric contraction of the muscle. Over 50percent of these injuries occur in athletes, classically in weight-lifters during bench press. Method: In this study, 13 cases of rupture of the pectoralis major muscle in athletes are presented. All patients underwent surgical repair. Physical findings and surgical technique are described. Magnetic resonance imaging was used in the diagnosis of all patients. Intra-operative findings correlated with the reported scans in 11 patients with minor differences in two patients. Results: During follow-up examination, six patients had excellent results, six had good results and one had a fair result. Eleven patients could return to sports activity at their pre-operative level. Among our patients we emphasise that of an orthopaedic resident who suffered a rupture of his pectoralis major tendon as an unusual complication of closed manipulation of an anterior shoulder dislocation. Conclusion: According to the literature and our experience, we suggest that only surgical repair of the pectoralis major rupture will result in complete recovery and restoration of the full strength of the muscle, which is essential for the active athlete

Upper limbs are commonly involved in Arthrogyposis Multiplex Congenita. They may be involved in isolation or in combination with lower limbs. There are two patterns of involvement in upper limbs. The most common (type I) pattern presents with adduction and internal rotation at the shoulder, extension at the elbow, pro-nation of the forearm and flexion deformity of the wrist, indicating involvement of the C5 and C6 segments. These deformities can be quite disabling and may require surgery to help improve function. We present our long-term results with pectoralis major transfer procedure (as modified by senior author MJB) to restore elbow flexion in seven patients (ten procedures). Results: Early results in all our patients were quite encouraging. Six patients retained useful power in transferred pectoralis major muscle and maintained the arc of flexion, which was attained following tricepsplasty. However, as children were followed up a gradually increasing flexion deformity and decreasing flexion arc were observed in eight elbows. The onset and progression of flexion deformity was gradual and progressive. The flexion deformity reached ninety degrees or more in all cases. Conclusions: Results of pectoralis major transfer to treat extension contracture of the elbow in arthrogryposis deteriorate with time due to development of recalcitrant flexion deformity of the elbow. Presently we recommend this procedure on one side only in cases of bilateral involvement because if one procedure is carried out it would be possible for this hand to get to the mouth for feeding and the other unoperated side would be able to look after the perineal hygiene

Introduction: The purpose of this study was to evaluate the results 9 to 12 years after the transfer of 3 distal parts of pectoralis major muscle to restore active elbow flexion in patient with arthrogryposis. Material and methods: From 1996 to 1999, elbow flexion was reconstructed in 9 upper extremities by 5 patient aged 4.3–9 years. The patients were clinically evaluated according to the subjective and objective assessment and examined electromyographically before the surgery and during the follow up. Last clinical examination was provided 8 to12 years after the surgery in patients aged 15 to 18 years. Results: 3–4 years after pectoralis major transfer, 6 very good and good results were achieved, the average active ROM of elbow ranged 15 to 95 degrees. The power of elbow flexion was graded as 4 and 4+. This method was unsuccessful in the remaining 3 cases, the patients were not able to reach the mouth with the hands because of limited elbow flexion. 9 to12 years after the surgery, the results were similar. 5 extremities remain very good and good. One deterioration was obvious. The ROM of elbow changed, namely the extension was mostly reduced even in very good and good evaluations (the average decrease was 13.8 degrees, the range −20 to +10 deg.). The active flexion was not changed in 5 elbows, or it was increased (the average increase 4,4 deg., the range 0–15 deg.). The final limitation of extension (30 – 50 degrees) does not restrict using the hands for perineal hygiene and the final active flexion (85–100 degrees) allows elevating the hands to the head for feeding and toilet. Discussion and Conclusions: From the analysis of unsuccessful results 3–4 years after the surgery it was obvious that all cases were related to very limited preoperative passive flexion of the elbow; restricted movement of the shoulder and failed distal fixation of the transferred muscle. After 9–12 years, the active elbow flexion and extension for raising the hands to the mouth and for toilet needs, respectively, remain in majority previously successful cases. Because most children reached the skeletal maturity, no further shortening of the transferred muscle and limitation of extension is expected. These findings do not concur with the literature reports. According to our results, the transfer of the pectoralis major represents the efficient method for permanent restoring of bilateral active elbow flexion with the remaining functional extension. The ROM does not change significantly after having reached the plateau 2 years postoperatively. The prerequisites for successful results are a minimum of 90 degrees of passive flexion of the elbow before the surgery, the active shoulder abduction of 80–90 degrees, long-term rehabilitation and successful fixation of the transferred muscle to the forearm

Introduction: Tumors of the axilla impose a surgical difficulty because they are usually large at presentation and in close proximity to the major neurovascular bundle of the upper extremity. Attempted tumor resection via the base of the axilla is difficult because of limited exposure of the axillary content and neurovascular bundle. The authors have used a safe and reliable exposure for these situations. Methods: Between 1980 and 1997, 35 patients underwent extensile exposure of an axillary tumor. Diagnoses included 19 primary and 16 metastatic tumors of the axilla. The axillary cavity was fully exposed via the deltopectoral groove after detachment and reflection of two layers of muscles: first, the pectoralis major and, second, the coracoid origin of the pectoralis minor, cora-cobrachialis, and the short head of the biceps muscle. This surgical approach allowed full tumor visualization and determination of the exact anatomic relation of the tumor to the neurovascular bundle and as a result, tumor respectability. Following resection, the pectoralis minor and conjoined tendons were reattached to the coracoid process with a nonabsorbable suture, and the pectoralis major was reattached to its insertion site on the proximal humerus in the same manner. Results: Exposure revealed a safe plane of dissection between the tumor and the major neurovascular bundle in 23 patients and invasion of the major neurovascular bundle in 12 patients who subsequently underwent a forequarter amputation. At the most recent follow-up, none of these patients had functional limitation, which could be attributed to the extensile approach itself. All patients gained their presurgical pectoralis major and biceps function. Complications in the group of patients that underwent tumor resection included three (13%) superficial wound infections. Due to intended enbloc resection of an involved nerve with the tumor, two nerve palsies (8.7%) were documented. None of the remaining 21 patients had numbness, paresthesias, or nerve pain. There were three (13%) local recurrences; two were managed with wide excision and adjuvant radiation therapy and one necessitated amputation. Conclusions: The extensile exposure of the axilla allows full visualization of axillary tumors. It allows determination of tumor respectability and safe and reliable resection, when indicated. This exposure is associated with good functional outcome and an acceptable morbidity and is recommended in the management of axillary tumors

Purpose of the study: Old tears of the subscapular muscle situated in the glenoid area are not accessible to direct repair and require locoregional muscle plasty. The clavicular portion of the pectoralis major can be used for reconstruction. The purpose of this study was to describe the operative technique and examine short-term outcome. Material and methods: Five patients, mean age 54 years (45–71 years) with an irreparable tear of the subscapularis in the glenoid area with fatty degeneration greater than grade two in the Goutallier classification were treated. Four had had previous surgery for acromioplasty associated with rotator cuff repair in two or implantation of a humeral prosthesis in one. The preoperative Constant score was 27.5 (mean, range = 8.5–54) due to invalidating pain, limited active mobility and reduced muscle force. Gerber’s lift-off test was positive for those patients for whom it could be performed. Plain x-rays evidenced anterior subdislocation of the humeral head in one case. Subscapular reconstruction was achieved using the entire clavicular portion of the pectoralis major which was dissected and sectioned at its distal insertion on the humerus then reinserted by transosseous suture onto the lesser tuberosity. The rehabilitation program started with active and passive mobility against gravity within a few days of surgery using biofeedback contraction of the muscle flap then active contractions two months postoperatively. Patients were reviewed at a mean 19 months (6–42 months) for clinical and radiological assessment. Results: Four patients had a painless shoulder with a negative lift-off test. The gain in active mobility was predominantly achieved with anterior elevation and abduction. Muscle force was weak leading to a low overall Constant score at revision (mean = 50, range = 30–63). Radiographically, the humeral head was centered exactly as on the preoperative films. There were no cases with a new anterior subdislocation nor an aggravation of a former subdislocation. Functional outcome was better in cases with a unique tear of the subscapularis. Discussion and conclusion: Open surgery is used for primary repair of recent tears of the subscapularis. This technique gives 80 p. 100 good and very good results. In case of symptomatic acromioclavicular osteoarthtisis, better long-term results can be obtained by using a tendodesis of the long biceps and resecting the lateral centimeter of the clavicle. In case of irreparable tears in the glenoid area, reconstruction by transfer of the clavicular portion of the pectoralis major can produce a stable painless shoulder with improved active moblity and normal clinical tests. This method provides anterior stability of the glenohumeral articulation and prevents any anterior subdislocation of the humeral head, thus protecting the joint from secondary degeneration

Introduction:. Tuberosity healing is strongly correlated with functional results in all series of three- and four-part fractures of the proximal humerus treated by hemiarthroplasty. We formed a working group to improve position of the implant and fixation of the tuberosities on an implant specifically intended for traumatology. Material and Methods:. An anatomic study on 11 cadavers and a prospective multicentre clinical study of 32 cases were performed to validate extrapolable original solutions at the patient scale: placement of the stem at a height indicated in relation to the insertion of the clavicular bundle of the pectoralis major, locking of the stem, placement (based on bone quality) of a variable volume metaphyseal frame (offset modular system® OMS®), avoiding medialisation of the tuberosities, and fixation of the tuberosities using strong looped sutures, brightly coloured so that they can be located more easily. Evaluation by Dash score and Constant score was correlated with positioning of the tuberosities using radiographs. Results:. The clinical study enabled a distance of the top of the head to pectoralis major of 5.5 cm +/− 5 mm to be determined, confirming the results of the anatomic study and data from the literature. The distal double-locking ancillary device and the suturing technique for the tuberosities using looped sutures was judged to be effective by all of the surgeons. 23 patients (5 males, 9 CT4 and 8 CT3) with an mean age 69,6 (33–90) were operated on by 3 senior surgeons and reviewed at a mean follow-up of 17,3 months (6–24). All patients were seen again at 3 months and 6 months and the average motion at last follow was abduction of 90,7° (140–40), active anterior elevation of 113,25° (160–60), and external rotation of 43,2°(55–30). One complication was noted: inadequate position of a locking screw. In the 17 patients operated without oms® 50% had adequate initial positioning of the tuberosities and 10% secondary displacement. In comparison the 6 patients operated with the oms® 100% had adequate initial positioning of the tuberosities and no secondary displacement occurred. Discussion:. The series from Sofcot, Boileau, and more recently Reuther yielded results of 40 to 66% malposition or nonunion of the tuberosities. The initial clinical results from our series are encouraging and demonstrate that using a variable volume metaphyseal frame in synthesis of the tuberosities with control of the height of the implant is reliable. This multicentre study should be extended by a more long-term analysis

Background:. It is not well known how different external loads influence shoulder kinematics and muscle activity in patients with shoulder prostheses. Study objective: define shoulder kinematics and determine the scapulothoracic contribution to total shoulder motion, in combination with shoulder muscle activity and the degree of co-contraction, of patients with total (TSA) and reverse shoulder arthroplasties (RSA) and healthy individuals during rehabilitation exercises using different loading conditions. Methods:. Shoulder motions (anteflexion and elevation in the scapular plane) of 17 patients (20 shoulders) with a TSA, 8 patients (9 shoulders) with a RSA and 15 healthy subjects were measured using anelectromagnetic tracking device. A force transducer recorded force signals during loaded conditions (without external load, 1 kg and elastic resistance). Electromyographic (EMG) activity of the deltoid (anterior, middle, posterior parts), latissimus dorsi, pectoralis major (clavicular and sternal parts), teres major and serratus anterior was recorded and the degree of co-contraction calculated. Results:. The scapula contributed more to movement of the arm in subjects with prostheses compared to healthy subjects and during loaded versus unloaded tasks. Glenohumeral elevation angles during anteflexion were significantly higher in the TSA than in the RSA group. Higher activity of the middle and posterior deltoid was found in the TSA group compared to healthy subjects and for the pectoralis major (sternal part) in the RSA group compared to TSA and healthy subjects. For all muscles, except the serratus anterior, activity was lower for unloaded tasks compared to 1 kg dumbbell and elastic band resistance. No main effect of group or load for degree of co-contraction was detected in both exercises. Conclusions:. Differences in contribution of the scapula to total shoulder motion between patients with different types of arthroplasties were not significant, but differed both compared to healthy subjects. Scapular kinematics of patients with shoulder arthroplasties were influenced by implementation of external loads, however, not by the type of load. There were no differences in muscle activity and degree of co-contraction between patient groups

The shoulder girdle is an extremely mobile joint. Rotator cuff tears alter the existing equilibrium between bony structures and muscles. The “subacromial impingement syndrome” resulting from this unbalance leads to an extension of the rotator cuff lesion. Many authors have postulated a “mechanism of compensation”, but its existence still requires evidence. According to this model, the longitudinal muscles of the shoulder and the undamaged muscles of the rotator cuff would be able to functionally compensate, supersede the function of rotator cuff, and reduce symptoms. The aim of this study was to evaluate muscular activation of the medium fibers of deltoid, the superior fibers of pectoralis major, the latissimus dorsi and the infraspinatus by a superficial electromyographic study (EMG) and the analysis of kinematics in patients with a massive rotator cuff tear. We evaluated 30 subjects: 15 had pauci-symptomatic massive rotator cuff tear (modest pain and preserved movement), and 15 were healthy controls. Paired t-test showed significant different activations (p< 0.05) of these 4 muscles between the pathological joint and the healthy one in the same patient. The unpaired t-test, after comparing the mean EMG values of the 4 muscles, produced a significant difference (p< 0.05) between the experimental group and control group. This study showed that a mechanism of muscular compensation is activated in patients suffering from rotator cuff tear, involving the deltoid and the infra-spinatus muscle, as already presented in literature, but also demonstrated the activation of 2 other muscles: the latissimus dorsi and the pectoralis major. It is, therefore, probable that, in these patients, these muscles, which would not normally pull the head of the humerus downwards, adapt in order to compensate for the pathological situation. We believe that these data are valuable in the surgical and rehabilitation planning in patients with a massive rotator cuff tear

We present the use of dynamic electromyographic analysis (DEMG) in the diagnosis of muscle patterning instability. DEMG’s were requested in 168 of 562 muscle patterning shoulders with suspected subclinical or clinically complex muscle patterning instability. An experienced neurophysiologist (blinded to the clinical findings and direction of instability) inserted dual-wire tungsten electrodes into pectoralis major, latissimus dorsi, infraspinatus and anterior deltoid. Muscle activity was recorded during rest, flexion, abduction, extension, and cross-body adduction. 5 investigations were abandoned. The timing and magnitude of muscle activity was noted and compared to the clinical diagnosis and direction of instability. DEMG identified a total of 204 abnormal muscle patterns in 163 shoulders. The examination was normal in 13 patients (8%). A single muscle was abnormal in 63 shoulders, 2 muscles in 55, 3 muscles in 9, and all 4 muscles in one shoulder. Over-activation of pectoralis major was identified in 58%, and latissimus dorsi in 70%, of shoulders with anterior instability. In posterior instability, latissimus dorsi was overactive in 76%, anterior deltoid in 14% and infraspinatus was under-active in 24%. Pectoralis major and Latissimus dorsi were both overactive in 38% of anterior, 29% of posterior and 38% of multidirectional instability. Abnormal muscle patterns were identified in 52 shoulders with subclinical muscle patterning. A further 98 shoulders had 134 clinically abnormal muscle patterns. These were confirmed by DEMG in 57 cases (sensitivity 43%), and DEMG’s were normal in 77 (specificity 43%). DEMG also identified 65 additional muscles as abnormal in the 98 clinically abnormal shoulders. DEMG performed by an experienced neurophysiologist provides additional information regarding abnormal muscle activation in selected complex or subtle cases of muscle patterning instability in which clinical examination has a low sensitivity and specificity

Purpose: Functional outcome after shoulder arthrodesis was evaluated to assess indications for the treatment of posttraumatic partial and total brachial plexus paralysis in adults. Material and methods: Twenty-seven patients who underwent glenohumeral arthrodesis for posttraumatic brachial plexus paralysis were reviewed. Eleven had radicular paralysis (C5, C6 and C5, C6, C7) and sixteen total paralysis. All patients recovered active elbow flexion. Shoulder reinnervation had failed in eleven patients. Before the arthrodesis, 22 patients could no use their paralysed limb. Mean time between direct neurological surgery and arthrodesis was 30 months for partial paralyses and 20 months for total paralyses. Glenohumeal screw fixation was used for the arthrodesis which was associated with an external fixation in 21. Results: Mean postoperative follow-up was 70 months. There were two cases of non-union which fused after revision and three cases of humerus fracture which occurred during the first six months after surgery. Pain related to inferior subluxation improved in six patients. There was no significant difference between the two groups for position of the fusion, or postoperative active motion (60° flexion, 60° abduction, 45° internal rotation and 7 to −9° external rotation). There was a significant difference in force which was greater for superior paralyses (11 kgf versus 7 kgf in flexion, 12 kfg versus 7 kgf in abduction, 6 kgf versus 2 kgf in external rotation and 11 kgf versus 4 kgf in internal rotation). The same was true for hand movement. The differences were statistically correlated with force of the pectoralis major. Conclusion: Glenohumeral arthrodesis provides significant improvement in function in patients with supraclavicular brachial plexus paralysis, even with a paralytic hand. Arthrodesis also allows reorienting surgical reinnervation to other functions such as hand movement. Shoulder force and hand movement are directly correlated with force of the pectoralis major

Introduction. Rehabilitation after shoulder arthroplasty is a fundamental in enabling patients achieve a good functional outcome. Therapists must consider the underlying diagnosis, operative technique employed and rotator cuff integrity, amongst other factors, in order to select the most appropriate exercise regime. There is an absence of comprehensive studies in the literature with regard to shoulder rotational exercises. Therefore, this study aimed to describe the shoulder girdle muscle activation strategies during eight commonly cited rotational shoulder exercises. Method. Thirty healthy subjects with no history of shoulder problems participated in the study. EMG was recorded from 16 shoulder girdle muscles (surface electrodes: anterior, middle and posterior deltoid, upper, middle and lower trapezius, upper and lower latissimus dorsi, upper and lower pectoralis major; fine wire electrodes: supraspinatus, infraspinatus, subscapularis and rhomboid major) using a telemetry based EMG system. Five external and three internal rotation exercises were included (table 1). Signal acquisition and processing were in accordance with standardised guidelines. Amplitude normalisation was to external and internal rotation maximum voluntary contraction as appropriate. Mean EMG amplitudes between exercises were compared using repeated measures ANOVA. Data for muscle groups was calculated by averaging the activation of the component muscles. Results. External Rotation Exercises: significantly higher levels of deltoid activation were seen in external rotation at 90° abduction compared to the other external rotation exercises (73.7% vs 12.4–27.2%; p < 0.001). Peri-scapular muscle activation was highest in external rotation at 90° abduction and prone external rotation (76.7–83.2% vs 28.2–45.5%; p = 0.013 − <0.001). Activation of latissimus dorsi and teres major was significantly higher during prone external rotation (64.1% vs 18.1–48.4%; p < 0.001). Activation of the rotator cuff muscles was similar across all exercises. Internal Rotation Exercises: the highest deltoid activity was seen during internal rotation at 90°abduction, followed by zero-position internal rotation. It was lowest during internal rotation at 0°abduction (261.6% vs 190.1% vs 40.9%; p = 0.003 − <0.001). A similar activation pattern was also seen for peri-scapular muscles. The highest activation of pectoralis major was seen during zero-position internal rotation (25.4% vs 4.9–15.7%; p = 0.002 − <0.001). Significantly higher levels of rotator cuff activation were seen during internal rotation at 90° abduction (325.0% vs 94.0–188.3%; p = 0.005–0.017). Discussion and Conclusion. This study provides a comprehensive description of muscles activation during common rotational shoulder exercises. It enables therapists to target specific muscles for rehabilitation following shoulder surgery, while minimising the activation of others. Understanding the activation profile of the shoulder girdle muscles during individual exercises forms the basis for exercise prescription and the development of tailored and individual physiotherapy protocols

Glenoid exposure is the name of the game in total shoulder arthroplasty. I can honestly say that it took me more than 5 years but less than 10 to feel confident exposing any glenoid, regardless of the degree of bone deformity and the severity of soft-tissue contracture. This lecture represents the synthesis of my experience exposing some of the most difficult glenoids. The basic principles are performing extensive soft-tissue release, minimizing the anteroposterior dimension of the humerus by osteophyte excision, making an accurate humeral neck cut, having a plethora of glenoid retractors, and knowing where to place them. The ten tips, in reverse order of importance are: 10.) Tilt the table away from operative side—this helps face the surface of the glenoid, especially in cases of posterior wear, toward the surgeon. 9.) Have multiple glenoid retractors—these include a large Darrach, a reverse double-pronged Bankart, one or two blunt Homans, small and large Fukudas. 8.) Remove all humeral osteophytes before attempting to retract the humerus posteriorly to expose the glenoid—this helps to decrease the overall anteroposterior dimension of the humerus and allows for maximum posterior displacement of the humerus. 7.) Make an accurate humeral neck cut—even 5mm of extra humeral bone will make glenoid exposure difficult. 6.) Optimal humeral position—it has been taught that abduction, external rotation, and extension is the optimal position. It may vary with each case. Therefore, experiment with humeral rotation to find the position that allows maximum visualization. This is often the position that makes the cut surface of the humerus parallel to the surface of the glenoid. 5.) Optimal retractor placement—my typical retractor placement is a Fukuda on the posterior lip of the glenoid, a reverse double-pronged Bankart on the anterior neck of the scapula, and a blunt Homan posterosuperiorly. Occasionally, a second blunt Homan anteroinferiorly is helpful, particularly in muscular males with a large pectoralis major. 4.) Laminar spreader for lateral humeral displacement—this can be helpful for posterior capsulorrhaphy or for posterior glenoid bone grafting. 3.) Maximal humeral capsular release—the release of the anterior capsule from the humerus must go well past the 6 o'clock position and up the posterior surface of the humerus. This aides in humeral exposure but also allows for more posterior displacement of the humerus during glenoid exposure. 2.) Anteroinferior capsular release or excision—extensive anteroinferior release or excision (my preference), allows for maximal posterior humeral displacement and also restores external rotation. 1.) Posterior or posteroinferior capsular release—release of the posteroinferior corner of the capsule from the glenoid results in a noticeable increase in posterior humeral retractability. In cases without substantial posterior subluxation, extensive release of the entire posterior capsule is performed

Last decade, a shift towards operative treatment of midshaft clavicle fractures has been observed [T. Huttunen et al., Injury, 2013]. Current fracture fixation plates are however suboptimal, leading to reoperation rates up to 53% [J. G. Wijdicks et al., Arch. Orthop. Trauma Surg, 2012]. Plate irritation, potentially caused by a bad geometric fit and plate prominence, has been found to be the most important factor for reoperation [B. D. Ashman et a.l, Injury, 2014]. Therefore, thin plate implants that do not interfere with muscle attachment sites (MAS) would be beneficial in reducing plate irritation. However, little is known about the clavicle MAS variation. The goal of this study was therefore to assess their variability by morphing the MAS to an average clavicle. 14 Cadaveric clavicles were dissected by a medical doctor (MH), laser scanned (Nikon, LC60dx) and a photogrammetry was created with Agisoft photoscan (Agisoft, Russia). Subsequently a CT-scan of these bones was acquired and segmented in Mimics (Materialise, Belgium). The segmented bone was aligned with the laser scan and MAS were indicated in 3-matic (Materialise, Belgium). Next, a statistical shape model (SSM) of the 14 segmented clavicles was created. The average clavicle from the SSM was then registered to all original clavicle meshes. This registration assures correspondences between source and target mesh. Hence, MAS of individual muscles of all 14 bones were indicated on the average clavicle. Mean area is 602 mm. 2. ± 137 mm. 2. for the deltoid muscle, 1022 mm. 2. ±207 mm. 2. for the trapezius muscle, and 683 mm. 2. ± 132 mm. 2. for the pectoralis major muscle. The sternocleidomastoid muscle has a mean area of 513 mm. 2. ± 190 mm. 2. and the subclavius muscle had the smallest mean area of 451 mm. 2. ± 162 mm. 2. Visualization of all MAS on the average clavicle resulted in 72% coverage of the surface, visualizing only each muscle's largest MAS led to 52% coverage. The large differences in MAS surface areas, as shown by the standard deviation, already indicate their variability. Difference between coverage by all MAS and only the largest, shows that MAS location varies strongly as well. Therefore, design of generic plates that do not interfere with individual MAS is challenging. Hence, patient-specific clavicle fracture fixation plates should be considered to minimally interfere with MAS

Rupture of the pectoralis major (PM) tendon is a rare yet severe injury. Several techniques have been described for PM fixation including a transosseus technique, when cortical buttons are placed at the superior, middle and inferior PM tendon insertion positions. The concern with this technique is the risk that bicortical drilling poses to the axillary nerve as it courses posteriorly to the humerus. This cadaveric study investigates the proximity of the posterior branch of the axillary nerve to the drill positions for transosseus PM tendon repair. Drills were placed through the humerus at the superior, middle and inferior insertions of the PM tendon and the distance between these positions and the axillary nerve, which had previously been marked, was measured using computed tomography (CT) imaging. This investigation demonstrates that the superior border of PM tendon insertion is the fixation position that poses the highest risk of damage to the axillary nerve. Caution should be used when performing bicortical drilling during cortical button PM tendon repair, especially when drilling at the superior border of the PM insertion. We describe ‘safe’ and ‘danger’ zones for transosseus drilling of the humerus reflecting the risk posed to the axillary nerve

The standard approach is through the deltopectoral interval. Among patients with prior incisions, one makes every effort to either utilise the old incision or to incorporate it into a longer incision that will allow one to approach the deltopectoral interval and retract the deltoid laterally. The deltopectoral interval is most easily developed just distal to the clavicle, where there is a natural infraclavicular triangle of fat that separates the deltoid and pectoralis major muscles even in very scarred or stiff shoulders. Typically, the deltoid is retracted laterally leaving the cephalic vein on the medial aspect of the exposure. The anterior border of the deltoid is mobilised from the clavicle to its insertion on the humerus. The anterior portion of the deltoid insertion together with the more distal periosteum of the humerus may be elevated slightly. The next step is to identify the plane between the conjoined tendon group and the subscapularis muscle. Dissection in this area must be done very carefully due to the close proximity of the neurovascular group, the axillary nerve, and the musculocutaneous nerve. Scar is then released from around the base of the coracoid. The subacromial space is freed of scar and the shoulder is examined for range of motion. Particularly among patients with prior rotator cuff surgery, there may be severe scarring in the subacromial space. Internal rotation of the arm with dissection between the remaining rotator cuff and deltoid is critical to develop this plane. If external rotation is less than 30 degrees, one can consider incising the subscapularis off bone rather than through its tendinous substance. For every 1 cm that the subscapularis is advanced medially, one gains approximately 20 to 30 degrees of external rotation. The rotator interval between the subscapularis and supraspinatus is then incised. This release is then continued inferiorly to incise the inferior shoulder capsule from the neck of the humerus. This is performed by proceeding from anterior to posterior with progressive external rotation of the humerus staying directly on the bone with electrocautery and great care to protect the axillary nerve. The key for glenoid exposure as well as improvement in motion is deltoid mobilization, a large inferior capsular release, aggressive humeral head cut and osteophyte removal

Glenoid exposure is the name of the game in total shoulder arthroplasty. I can honestly say that it took me more than 5 years but less than 10 to feel confident exposing any glenoid, regardless of the degree of bone deformity and the severity of soft-tissue contracture. This lecture represents the synthesis of my experience exposing some of the most difficult glenoids. The basic principles are performing extensive soft-tissue release, minimizing the anteroposterior dimension of the humerus by osteophyte excision, making an accurate humeral neck cut, having a plethora of glenoid retractors, and knowing where to place them. The ten tips, in reverse order of importance are: 10.) Tilt the table away from operative side—this helps face the surface of the glenoid, especially in cases of posterior wear, toward the surgeon. 9.) Have multiple glenoid retractors—these include a large Darrach, a reverse double-pronged Bankart, one or two blunt Homans, small and large Fukudas. 8.) Remove all humeral osteophytes before attempting to retract the humerus posteriorly to expose the glenoid—this helps to decrease the overall anteroposterior dimension of the humerus and allows for maximum posterior displacement of the humerus. 7.) Make an accurate humeral neck cut—even 5mm of extra humeral bone will make glenoid exposure difficult. 6.) Optimal humeral position—it has been taught that abduction, external rotation, and extension is the optimal position. It may vary with each case. Therefore, experiment with humeral rotation to find the position that allows maximum visualization. This is often the position that makes the cut surface of the humerus parallel to the surface of the glenoid. 5.) Optimal retractor placement—my typical retractor placement is a Fukuda on the posterior lip of the glenoid, a reverse double-pronged Bankart on the anterior neck of the scapula, and a blunt Homan posterosuperiorly. Occasionally, a second blunt Homan anteroinferiorly is helpful, particularly in muscular males with a large pectoralis major. 4.) Laminar spreader for lateral humeral displacement—this can be helpful for posterior capsulorrhaphy or for posterior glenoid bone grafting. 3.) Maximal humeral capsular release—the release of the anterior capsule from the humerus must go well past the 6 o'clock position and up the posterior surface of the humerus. This aides in humeral exposure but also allows for more posterior displacement of the humerus during glenoid exposure. 2.) Anteroinferior capsular release or excision—extensive anteroinferior release or excision (my preference), allows for maximal posterior humeral displacement and also restores external rotation. 1.) Posterior or posteroinferior capsular release—release of the posteroinferior corner of the capsule from the glenoid results in a noticeable increase in posterior humeral retractability. In cases without substantial posterior subluxation, extensive release of the entire posterior capsule is performed. Following these steps will help the surgeon to gain adequate glenoid exposure, even in the most difficult cases