Background

In elderly patients with complex proximal humerus fractures and osteoporotic bone reconstruction is not always possible. Although hemiarthroplasty is an alternative, non-union or tuberosity migration can lead to inferior functional results. Implantation of a Reverse Total Shoulder Arthroplasty (RTSA) seems to be an interesting alternative. In the present study we retrospectively analyzed the short-term results of RTSA for complex proximal humerus fractures in the elderly.

Background: Progression of fatty infiltration of the suscapularis muscle subsequent to total shoulder arthroplasty is frequent and may be an underestimated problem. The approach with osteotomy of the lesser tuberosity led to consistent bone to bone healing with neither retraction nor overtensioning of the musculotendinous unit. However, in a previous study, fatty infiltration of the subscapular muscle had progressed at least by one stage in 45% of the patients’ shoulders. We hypothesized that anterior approach to the shoulder joint with release of the subscapularis muscle would lead to a direct or indirect subclinical damage of the subscapular nerve and would be an explanation for the progression of fatty infiltration of the muscle.

Methods: Nine Shoulders in eight consecutive patients had received a total shoulder arthroplasty using an anterior approach with osteotomy of the lesser tuberosity. The mean age at time of operation was 67 years. Patients were followed clinically including the Constant score and a detailed neurological examination, as well as radiographically with pre–and postoperative MRI’s, CT’s and standard radiographs at 6–and 12 months thereafter. Neurophysiological assessment was performed using a new pre–intra–and postoperative electromyographic technique for the subscapular muscle. Fibrillation and sharp waves as spontaneuous activities of the motor unit potentials (MUP) indicated direct signs of denervation. Incomplete interference patterns (IP’s) indicated an incomplete innervation pattern as an indirect sign of denervation.

Results: After a one year follow up, 89% of the patients were very satisfied or satisfied with the result. The relative Constant Score improved from an average of 50 percent preoperatively to an average of 96 percent postoperatively (p=0,008). That corresponds to a postoperative subjective Shoulder value of 89 percent. From preoperative to 6–and 12-months postoperative, the average degree of fatty infiltration of the subscapular muscle progressed in an almost significant extent (0.6, 1.1, and 1.6 respectively; p=0.056).

Intra–and postoperatively, there were neither fibrillations and sharp waves of the MUP’s as direct signs, nor incomplete (IP’s) of the motor unit of the subscapular nerve as indirect signs of denervation.

Conclusion: Total Shoulder Arthroplasties perfomed by an anterior approach using an osteotomy of the lesser tuberosity yields good results with a high satisfaction rate. Comparable to our previous study, there are signs of progression of fatty infiltration of the subscapularis muscle within the first year subsequent to total shoulder arthroplasty. However, there were no signs of direct or indirect subclinical damage of the subscapular nerve during total shoulder arthroplasty.

INTRODUCTION: Chronic experimental rotator cuff tears are associated with muscle retraction, atrophy, fatty infiltration, a pronounced change in the pennation angle of the muscle and consequent shortening of muscle fibres. It was the purpose of this investigation to study whether slow, continuous elongation of the musculotendinous unit can revert the pennation angle and elongate the shortened muscle fibres.

MATERIAL AND METHODS: The infraspinatus tendons of twelve sheep were released. After retraction of the tenotomised musculotendinous unit, the infra-spinatus was elongated one mm per day using a new elongation-apparatus. After restoring the approximate original length, the tendon was repaired back. Muscular architecture (retraction and pennation angle), fatty infiltration (in Hounsfield units=HU) and muscular cross sectional area (in % of the mean control side) were analyzed at start, at the time before elongation, at the time of repair and six and eighteen weeks thereafter.

RESULTS: In four sheep the elongation failed technically. In the other eight sheep, elongation could be achieved as planned. After retraction of 29mm ± 6 mm after 16 weeks (14% of original length, p=0.008), the mean traction time was 24 days ± 6 days with a mean traction distance of 19 mm ± 4 mm. At sacrifice the mean pennation angle increased in the failed sheep from 30° ± 6° up to 55° ± 14° (p=0.035). In those sheep in which traction was applied, the mean pennation angle was not different to the control side (29.8° ± 7.5° vs. 30° ± 6°, p=0.575). Compared to preoperative, there was a significant increase in fatty infiltration (36 HU, p=0.0001) and decrease of the muscular cross sectional area of 43 % (range 21% to 67%, p=0.0001) at 4 months. In the sheep in which traction could be achieved, fatty infiltration remain unchanged (36 HU ± 6 HU vs 38 HU ± 4 HU, p=0.438) and atrophy decreased by 22% (range 10% to 33%) after 6 weeks of continuous traction (p=0.008).

CONCLUSION: Continuous experimental elongation of a retracted musculotendinous unit is technically feasible and might lead to recovery of the muscle architecture, partial reversibility of atrophy and, arrest of progression of fatty infiltration.

Background: It is commonly believed that rotator cuff tears do progress in size over time. Recent reports suggest that tear progression may not be necessarily true. It was the purpose of this study to review non-operatively treated isolated supraspinatus tears especially in terms of tear size progression.

Methods: Inclusion criteria were non-operatively treated isolated full-thickness tears of the supraspinatus, MRI at time of diagnosis available, and patients willing to undergo an additional MRI after more than 2 years after diagnosis. Twenty-four patients (20 men, 4 women) with an average at time diagnosis of 51 years identified and reviewed with MRI and clinically based on the Constant score.

Results: The average follow-up was 46 (27–87) months. The Constant score (not available at time of diagnosis) at follow-up averaged 75 points (relative Constant score 86%). Overall the average tear size did not change significantly over time (366mm2 at follow-up versus 393mm2 at time of diagnosis, p > 0.05). In 2 patients the tear was not detectable any longer on MRI suggesting that it was healed, in 7 patients the tear was smaller, in 10 patients it did not change over time and only in 5 patients it progressed.

Discussion and Conclusion: Non-operatively treated isolated supraspinatus tears were unchanged, smaller or even healed in 79% of the patients after a follow-up period of more than 4 years. This suggests that supra-spinatus tears do not necessarily progress over time and even have a potential to heal.

Introduction: Treatment and outcome of patients with rheumatoid arthritis and distal humerus fractures is not well established.

Methods: Between 1982 and 2002 twenty-four elbows in twenty-two patients (eleven men, eleven women) treated for acute distal humerus fractures were retrospectively reviewed. The average age at time of the fracture was 64 years. Eleven elbows were immediately treated with a total elbow arthroplasty (TEA) type Coonrad-Morrey (CM), six elbows had underwent open reduction and internal fixation (ORIF), and seven elbows were referred to our institution after failed ORIF elsewhere and were revised with an TEA (CM).

Results: At an average follow-up of 52 months the Mayo Elbow Performance Score (MEPS) averaged in the eleven elbows with an immediate TEA 96 points and in the six elbows with ORIF 93 points (p=0.79). In the seven elbows with TEA after failed ORIF there was a trend towards a less favorable outcome (MEPS: 86 points) but the differences was not significant compared to immediate TEA (p=0.31) and ORIF (p=0.53). Patients with failed ORIF and a subsequent TEA had an average of 3 operation per elbow with one patient ending in elbow resection after an infected TEA. Patients with immediate TEA had an average of 1.3 operations and patients with successful ORIF 1.2 interventions.

Discussion and Conclusion: Distal humerus fractures in patients with rheumatoid arthritis can be treated successfully with an immediate TEA or ORIF. There is a trend towards a poorer clinical outcome in patients with TEA after failed ORIF.

Introduction: Proximal radio-ulnar synostosis is a rare complication after distal biceps tendon repair. Synostosis results in usually painfree limitation of forearm rotation and loss of function. The outcome after synostosis excision has not been demonstrated.

Methods: Between 1987 and 2003 twelve patients were identified with radio-ulnar synostosis and retrospectively reviewed clinically and radiographically. All patients initially experienced a complete distal biceps tendon rupture after lifting heavy objects. The average time to repair was fourteen days.

Results: These twelve patients underwent excision of synostosis as early as two months post repair and as late as 18 months. The average age at time of excision was forty-five years and the dominant arm involved in seven patients. All received postoperative idomethacin for four weeks and only six received additional postoperative irradiation. The average follow-up was fifty-nine months. Function revealed an average pre-operative rotational arc of 19, six patients were ankylosed in a neutral position. The postoperative arc was 138 (p = 0.007). Flexion and extension was essentially normal preoperatively and postoperatively. All twelve patients demonstrated no pain pre- and postoperatively. All patients were very satisfied with the result. There were no complications after excision. Radiographically there was no recurrence of ectopic bone formation.

Discussion and Conclusion: Excision of proximal radio-ulnar synostosis following distal biceps repair results in a significant improvement of limited forearm rotation and returning patients to a pain free functional rotational arc with a high satisfaction rate.

Introduction: Structural failure of a rotator cuff repair, if associated with pain and severe dysfunction, represents a treatment challenge. Depending on the size of the retear ,the degree of fatty degeneration of the involved muscles, retraction of the musculotendinous unit, as well as age and activity level of the patient, treatment options include re-repair, re-repair with tendon transfer, glenohumeral arthrodesis and inverse total shoulder (Delta) prosthesis. The purpose of this study was to review the outcome of treatment of failed rotator cuff repairs and to compare the results of the four most important types of treatments.

Material and methods: From 1991 till 2002, we retrospectively analysed 80 patients, who underwent revision surgery of the shoulder after failed primary cuff repair. Out of them, 33 had a rerepair, 15 were treated with a delta prosthesis, 17 with a latissimus dorsi-and 15 with a pectoralis major-transfer. Data assessment included pre- and postoperative Constant Score and complication rate. Average follow-up time was 51 months.

Results: After rerepair of the rotator cuff, patients showed a significant gain in subjective shoulder value, rel. Constant Score and reduction of pain(p< 0.05), but range of motion and strength remained unchandged. After additional latissimus-dorsi-or pectoralis major-transfer no significant gain was seen in either subjective shoulder value, nor rel. Constant Score. After Implantation of delta prosthesis, significant improvement was seen in subjective shoulder value, relative Constant score, range of motion and strength (p< 0.05). These improvements were significantly better than in the other groups (p< 0.05). Complication rate was the highest in the delta group.

Conclusion: After failed rotator cuff repair, attempts of rerepair allow good subjective results by reducing pain and maintaining range of motion. Although range of motion is maintained after additional latissimus dorsi-and pectoralis major-transfer, subjective and objective results are not satisfying. After implantation of a delta prosthesis, very good subjective and objective outcome can be predicted, although results are slightly compromised by the high complication rate.