This study evaluates the position of the long head of biceps tendon using ultrasound following simple tenotomy, in patients with arthroscopically repaired rotator cuff tears.

In total, 52 patients with a mean age of 60.7 years (45 to 75) underwent arthroscopic repair of the rotator cuff and simple tenotomy of the long head of biceps tendon. At two years post-operatively, ultrasound revealed that the tendon was inside the bicipital groove in 43 patients (82.7%) and outside in nine (17.3%); in six of these it was lying just outside the groove and in the remaining three (5.8%) it was in a remote position with a positive Popeye Sign. A dynamic ultrasound scan revealed that the tenotomised tendons had adhered to the surrounding tissues (autotenodesis).The initial condition of the tendon influenced its final position (p < 0.0005). The presence of a Popeye sign was statistically influenced by the pre-operative co-existence of supraspinatus and subscapularis tears (p < 0.0001).

It appears that the natural history of the tenotomised long head of biceps tendon is to tenodese itself inside or just outside the bicipital groove, while its pre-operative condition and coexistent subscapularis tears play a significant role in the occurrence of a Popeye sign.

Purpose of this study is to create an experimental model of electrophysologic evaluation of the supraspinatus muscle on rats, after traumatic rupture of its tendon.

The population of this study consisted of 10 male Sprague Dawley rats weighting 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The scapula was immobilized, and the supraspinatus tendon was attached to a force transducer using a 3–0 silk thread. A dissection was performed in order to identify the suprascapular nerve, which was then stimulated with a silver electrode. Stimulations were produced by a stimulator (Digitimer Stimulator DS9A) and were controlled by a programmer (Digitimer D4030). Fiber length was adjusted until a single stimulus pulse elicited maximum force during a twitch under isometric conditions. Rectangular pulses of 0.5 ms duration were applied to elicit twitch contractions. During the recordings, muscles were rinsed with Krebs solution of approximately 37 8C (pH 7.2–7.4) and aerated with a mixture of 95% O2 and 5% CO2. The output from the transducer was amplified and recorded on a digital interface (CED).

The following parameters were measured at room temperature (20–21 8C): single twitch tension; time to peak; half relaxation time; tetanic tensions at 10, 20, 40, 80 and 100 Hz; and fatigue index, which was evaluated using a protocol of low frequency (40 Hz) tetanic contraction, during 250 ms in a cycle of 1 s, for a total time of 180 s. The fatigue index value was then calculated by the formula [fatigue index=(initial tetanic tension − end tetanic tension) ∗ 100/(initial tetanic tension)]. In the end, the transducer was calibrated with standard weights and tensions were converted to grams.

The mean single twitch was 8.2, the time to peak 0.034 msec and the half relaxation time 0.028 msec. The strength of titanic muscle contractures was 5.7 msec at 10Hz and 17.7 at 100Hz. Finally, the fatigue index was calculated at 48.4.

We believe that electrophysiologic evaluation of the supraspinatus muscle in rats will help us understanding the pathology of muscle atrophy after rotator cuff tears and possibly the functional restoration after cuff repair

AIM

Retrospective study comparing the effectiveness of preoperative autologous blood donation versus intra-operative blood saver systems in minimizing the need for allogeneic blood transfusion in scoliosis surgery.

Intra-articular shoulder pathology has been recognised in more detail following widespread use of shoulder arthroscopy. The purpose of this epidemiological study is to present the incidence and exact type of SLAP lesions in our operated population and to correlate them with the presence of other shoulder lesions.

Between 2004 and 2010 425 patients underwent shoulder arthroscopy in our department (311 for rotator cuff tears or subacromial impingement, 102 for shoulder instability, 12 for SLAP lesions). Eighty-two SLAP lesions (19.2% overall) were recognized during these procedures.

In 44 cases the lesion was SLAP type I (53.6%), in 10 type II (12.2%), in 1 type III (1.2%), in 1 type IV (1.2%), in 24 type V (29.26%) and finally in 2 type VI (2.43%). In more detail SLAP I lesions were associated in 8 patients with subacromial impingement syndrome, in 33 with RC tear and in 3 patients with anterior instability. Type II, III and IV were preoperatively diagnosed, while type V and VI lesions were found in patients with chronic anterior shoulder instability.

SLAP lesions are diagnosed more accurately during shoulder arthroscopy rather than with plain shoulder MRI scan. In our study population only 12 cases were accurately diagnosed with a pre-operative MRI scan, while the remaining 70 cases were missed. Additionally, there was significant correlation between rotator cuff problems and SLAP I lesions, while chronic shoulder instability was associated with SLAP V and VI (25.4% of patients with instability).

Shoulder arthroscopy not only has changed SLAP lesion diagnosis and treatment but also reveals the correlation of various SLAP lesion types with specific shoulder pathologies.

Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis.

Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty.

Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the axillary nerve was observed; this resolved 3 months postoperatively. Continuous clinical improvement was observed in some patients up until 18 months postoperatively.

Our clinical results are very satisfactory and reveal that reverse shoulder arhroplasty is a very good option for a broad spectrum of pathologic shoulder conditions.

Although, reverse shoulder arthroplasty has initially been introduced for rotator cuff arthropathy, its application has been expanded on fracture sequelae, chronic dislocations and even comminuted fractures of the humeral head in elderly patients. The purpose of this study is to present our experience and the mid-term clinical results of this type prosthesis.

Between 2006 and 2008 16 reverse shoulder arthroplasties have been carried out in our department. Fourteen patients were female and 2 male with an average age of 72.4 years (55–81). Eleven patients had true rotator cuff arthropathy, 3 malunion of 4-part fractures, one chronic anterior shoulder dislocation and finally one patient had bilateral chronic posterior shoulder dislocation. In 2 cases we used the Delta prosthesis and in a further 14 cases the Aquealis Arthroplasty.

Routine postoperative follow up was at 3,6,12 and 24 months and included plain radiographic control and clinical evaluation with the Constant Shoulder Score. All patients report significant pain relief and an average improvement of the Constant Score from 40.5 to 72.3. Two patients had anterior dislocation of the prosthesis 4 days postoperatively and we proceeded to the application of a 9 mm metal spacer and bigger polyethylene size. In one patient neuroapraxia of the axillary nerve was observed; this resolved 3 months postoperatively. Continuous clinical improvement was observed in some patients up until 18 months postoperatively.

Our clinical results are very satisfactory and reveal that reverse shoulder arhroplasty is a very good option for a broad spectrum of pathologic shoulder conditions.

Purpose of this study is to create an experimental model on rats for EMG evaluation of the supraspinatus muscle after traumatic rupture of its tendon.

The population of this study consisted of 5 male rats of 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The electrode of a stimulator was placed under suprascapular nerve and the supraspinatus tendon was sutured on a transducer for digital record of the produced signal. Initially we found the resting length and the electric intensity for higher muscle contracture. The parameters that were evaluated after single contracture (single twitch) were strength, time to peak, half relaxation time. Furthermore, it was evaluated the strength of tetanic contractures at 10,20,40,80,100 Hz (Stimulation for 350msec each time).Finally it was evaluated the muscle fatigue with stimulation at 40Hz for 250msec and total duration of 3 minutes. Fatigue index was calculated according to the decrease of titanic muscle contracture (Initial value-Final Value/Initial Value x 100)

Our results are presented in mean ± sd. The single twitch was 8.2(5.1),the time to peak 0.034(0.02) msec, the half relaxation time 0.028(0.008)msec. The strength of titanic muscle contractures was 5.7msec at 10Hz and 17.7 at 100Hz. Finally the fatigue index was calculated at 48.4.

We believe that EMG evaluation of the supraspinatus muscle in rats will help us understanding the pathology of muscle atrophy after rotator cuff tears and possibly the functional restoration after cuff repair.

Autogenous iliac bone grafts has been proved to be the most reliable mean to achieve a solid fusion in spine surgery. The purpose of our study is to evaluate that healing process of the ilium after been used as donor site of bone grafts in the treatment of adolescent idiopathic scoliosis.

Eighteen patients underwent posterior spinal fusion for progressive adolescent idiopathic scoliosis between 1989 and 1993. Thirteen patients were female and five were male with a mean age at the time of operation of 14.6 years (12–33). The same surgeon performed all procedures with nearly identical technique using the Hart-shill frame as stabilizing instrumentation. The average of the number of levels involved in spinal fusions was 10.3 levels. In all cases the autogenous bone graft used was harvested from the right posterior iliac crest.

All patients were reviewed at least fourteen years after surgery. CT scans were performed in all 18 patients in order to evaluate the status of ossification at the donor site.

CT scans of the ilium showed that bone deficit was present in 9 cases (50%) and in 9 cases (50%) it was found that both cortical and cancellous bone was fully restored. Using the T-student test we found that bone reformation was independent from the number of levels fused and the amount that was harvested. Our important result is that younger patients with smaller Risser’s line have greater capability to restore bone stock at this area.

In conclusion ICBG remains the most effective mean to achieve fusion in spinal surgery. The iliac wing and especially the periosteum of immature patients (Risser 3,4) seem to have great capabilities to regenerate the bone defects

Periprosthetic fractures are rare complications (0.3%–2.5%) of total knee and hip Arthroplasty. Purpose of this study is to present our experience and the mid-term clinical results of periprosthetic fracture care.

Between 2005 and 2009 nineteen femoral periprosthetic fractures were treated in our department. Seven patients with TKA had supracondylar fractures, type II according to Lewis and Rorabec classification. Twelve patients with THR had type B2 fractures according to Vacouver Classification. Seven patients were men and 12 women with average age 78.15 years. Femoral shaft fractures were treated with ORIF and DCP 4.5mm femoral plate in 8 cases, revision THR in 3 cases and 4.5mm plate with wires in one case. Supracondylar fractures were treated with ORIF abd LCP plate 4.5mm in 5 cases, Ilizarov fixator in one case and DCS plate in the last case. The average follow up was 22 months postoperatively.

Fracture healing observed in 16 patients at an average of 6 months postoperatively. No infection or non union complicated our treatment goal. Three patients died at an average of 2 months postoperatively. One should point out that mobilization and return to previous activity level is very difficult for these patients, despite fracture healing. Best clinical results observed with DCP and LCP 4.5mm plates.

Periprosthetic fractures are serious and complex complications of an arthroplasty that require stable osteosynthesis and primary patient mobilization.

The long head of biceps tendon has been proposed as one of the pain generators in patients with rotator cuff tears. Many surgeons routinely perform tenotomy or tenodesis of the LHB especially in cases of large or massive RC tears. Purpose of this study is to evaluate the condition and position of the tenotomised LHB at a minimum of one year postoperatively.

Between 2006 and 2008 96 patients (41 men and 55 women) with RC tears were treated arthroscopically in our clinic, with an average age of 61.2 years (56–80). In 57 cases we proceeded to tenotomy of the LHB. Thirty one of them were available for ultrasound evaluation of the condition and the position of the tenotomised LHB one year post –tenotomy.

Intraoperatively the lesions of the LHB varied in degrees from significant hypertrophy- Hourglass deformity (6 cases), subluxation (10 cases), tendinitis (25 cases) to fraying (10 cases). Twelve months postoperatively all the patients reported pain relief and satisfaction from the operation, even in irreparable tears.

On ultrasound control the tendon was not found in the bicipital groove or was at its peripheral margin in 10 cases (31%) with only 3 patients having a positive Popeye sign. In the remaining patients the tendon was adhered on the wall of the groove (natural tenodesis).

Our results suggest that simple tenotomy of LHB results in pain relief and maintenance of muscle strength. The low percentage of Popeye Sign disputes the necessity for tenodesis, even in younger patients.

During the last decade intramedullary nailing of the humerus became a more popular operation. Modern nails are successfully used in treatment of fractures involving proximal, distal and middle shaft humerus, as well as pseudarthrosis and pathological fractures. Minimal invasive insertion lessens the complications from neurovascular and soft tissue damage without significant delay in healing period in comparison with compression plates. Aim of our study is to present our experience and the clinical outcomes of this method.

Material and Methods: Between 1998 and 2006 50 patients (52 Fractured Hunerus) were treated in our department. The mean average age was 35 y.o. (18–55 y.o.) and the operation time was 2.5 days after the injury. All fractures were acute (Unstable, comminuted, in both limps or polytrauma patients). In 25 cases we used the unreamed Synthes nail (22 Cases Antegrade insertion and 13 Cases retrograde insertion). In 27 cases we used the T2 or Polarus reamed nail (23 cases Antegrade insertion and 4 cases retrograde insertion). The mean duration of the surgery was 1.3 h.

Results: The healing time was 12.5 weeks (8–16) and no preudarthrosis occurred. There were 4 radial nerve palsies (2 primary – 2 after operation) that were neuroapraxia and resolved in almost 6 weeks. One antegrade nail (Polarus-reamed) was malpositioned and applicated again and in 2 retrograde nails the posterior cortex of the fossa was fractured (in one case we changed fixation method-plates). No infection occurred. In some patients full abduction, elevation and external rotation achieved in 6 weeks and in some others after 3 months.

Conclusions: Intramedullary nailing of the humerus is a very good solution of fracture treatment, especially in multiple trauma patients. In good hands offers good fracture alignment and adequate stability. Postoperative rehabilitation period is short, uneventful healing is common and almost excellent results always appear.