Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears.

The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Cite this article: Bone Joint J 2024;106-B(9):970–977.

Introduction

A new triggered electromyography test for detection of stimulus diffusion to intercostal muscles of the contralateral side during thoracic pedicle screw placement was evaluated. Experimental research was carried out in order to determine if, using this test, neural contact at different aspects of the spinal cord and nerve roots could be discriminated.

Introduction and Objectives: meniscal lesions in the avascular zone are difficult to heal because of the poor biological potential of the avascular tissue. Little is known about the molecular mechanisms that develop after a meniscal lesion in this low activity zone. The purpouse of this study is to determine the levels of gene expression of five different growth factors (IGF, IL-1β; TGF-β, PDGF-β and VEGF) in the first three weeks after a meniscal lesion in the avascular zone of rabbit menisci.

Materials and Methods: 28 white female New Zealand rabbits were used in this study. Through a small arthrotomy a 5mm longitudinal lesion was performed in the avascular zone of the anterior horn of the medial meniscus of each rabbit. The rabbits were sacrificed after 0, 1, 3, 7, 14 and 21 days (4 rabbits each). After sacrifice, the zone in which the meniscal lesion was performed was disected from the rest of the mensicus. It was then divided in two parts: a peripheric vascular zone and a central avascular zone. After ARNm extraction cuantitative PRC anaylisis with Sybergreen technology was performed using specific primers for each gene.

Results: There were significant expression increases of IGF, TGF-β and PDGF-β, in the vascular zone at two weeks but no variations of note in these genes in the avasacular zone. The expression of IL-1β is increased in the first day after injury in both zones but only last up to the thrid day in the vascular zone. There is an increase in VEGF expresion in the avascular zone at two weeks that is related to a symetric decrease in the vascular zone.

Introduction and Objectives: patellar tendinopaty (or jumper’s knee) is a frequent problem that affects active young adults. In some cases the different conservative treatment options are innefective and surgical treatment is considered. The purpouse of this study is to determine if repeated intratendinous inyections of platelet rich plasma (PRP) are effective for the treatment of these refractary cases.

Materials and Methods: Eight consecutive patients (4 males and 4 females, mean age 24+/−5,9) who presented refractary patellar tendinopathies were included. All patients had presented symptoms for at least 6 months and had recieved treatmet for at least 3 months. All patients had been subjected to activity limitation, physical therapy, NSAID’s and laser and ultrasound therapy. In 3 cases corticosteroid inyections had been used. The subjects were assesed before treatment and 3 months and one year later with a Visual Analoge pain Scale (0 to 100mm, VAS), the Victorian Institute of Sport Assessment Patellar tendinopathy assesment scale(VISA-P) and the Lysholm score. Treatment consisted of 3 infiltrations (one week apart) of 3 cm3 of PRP extracted from their own blood with the GPS^® system (Biomet, Warsaw, Indiana, U.S.A). The PRP was infiltrated at the level of the tender tendon and inmediately behind the tendon at the proximal tendinous insertion and 1 cm distal to it through a single cutaneous puncture.

Results: Of the 8 patients, 7 presented a significant increase (more than 20 points) in the VISA-P score and 1 did not present any noticeable improvement. No complications related to the injections were observed. The VISA-P score increased from a pretreatment mean of 29 +/− 10.7 to 79 +/− 10.7 at one year (significant differences, p< 0.001). A similar decrease was observed in the VAS pain score (pretreatment values of 75+/−28 to one year values of 21+/−19). There were not significat differences in the Lysholm score.

Conclusions: PRP seems to be a possible alternative to surgical treatment in refractary patellar tendinopathy.

Various studies have demonstrated that menisci heal in the vascular region but do not heal in the avascular area. Experimental studies of the promotion of meniscal healing in the avascular area have involved the application of fibrin clot, fibrin glue to the injured area, as well as the construction of an access chanel to the vascular regiòn, all of them with poor results. The multilineage potential of adult stem cells has been characterized extensively. The adipose tissue has been described as a useful source of adult stem cells. We try to show that the use of stem cells from the adipose tissue may promete meniscal healing in the avascular area.

Twelve New Zealand white rabbits with a mean weight of 3 kg were used. The medial meniscus of both knees was aproached, and was performed a longitudinal tear in the avascular area in the anterior horn with a mean length of 0.5 cm. All the tears were sutured with one vertical stitch of nonabsorbable suture. In each rabbit a solution with 1 00 000–1 000 000 stem cells from the fat was introduced in one of the knees, and the other one was used as a control. The rabbits were killed at 12 weeks, and a macro-microscopic study of the meniscus was done, and also a inmunohistochemistry study for the stem cells.

The incidence of healing was better in those menisci with the stem cells solution. Three total and three partial healing was obtained in the stem cells group and none in the control group. The inmunohistochemistry showed that the stem cells were in the repair zone.

We think that stem cells will be very useful in the treatment of the lesion in the avascular area of the meniscus.

Introduction and purpose: The relationship between congenital heart disease and the increased prevalence of scoliosis is well known, although the same cannot be said about the etiology of scoliosis in these patients. Although thoracotomy is often associated to scoliosis, median sternotomy has so far not been identified as an etiological agent. he purpose of the study is to determine if patients with congenital heart disease who are subjected to a median sternotomy show a higher prevalence of spine deformities.

Materials and methods: A retrospective review is made of patients operated on for congenital heart disease through median sternotomy before the age of 8, assessing the development of spine deformities. Simple chest radiographs of 128 patients were studied once they reached skeletal maturity and it was observed that they presented no spinal or costal deformities before surgery.

Results: The prevalence of scoliosis was 34.3%; 16 of these patients (12.5%) had curves of more than 20° and 33 (25.8%) had thoracic kyphosis of less than 20°. Patients operated on before the age of 18 months had a significantly higher risk to develop scoliosis as compared with those treated later (odds ratio: 3.48; p=0.016). The development of scoliosis was not related with the type of cardiac malformation present.

Conclusions: There is a high prevalence of scoliosis in patients subjected to a median sternotomy for a congenital heart pathology. The prevalence of scoliosis increases in patients operated on at younger ages.