Aims

Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model.

Drilling through bone is a complex action that requires precise motor skills of an orthopedic surgeon. In order to minimize plunging and soft tissue damage, the surgeon must halt drill progression precisely following penetration of the far cortex. The purpose of this study was to create a low-cost and easy-to-use drilling simulator to train orthopedic residents in reducing the drill plunging depth. This prospective observational study was performed in the division of orthopedic surgery of a single tertiary medical center. The participants included 13 residents and 7 orthopedic specialists. The simulator consisted of a synthetic femur bone model and ordinary modeling clay, and the training unit consisted of a disposable plastic tube (∼US$14), clamps (∼US$58) and a power drill + drill bit (standard hospital equipment). Plunging depths were measured by the simulator and compared between orthopedic specialists, the 6 “senior residents” (3+ years) and the 7 “junior residents” during a training session. Measurements were taken again 2 weeks following the training session. Initially, the plunging depths of the junior residents were significantly greater compared to those of the orthopedic specialists (7.00 mm vs 5.28 mm, respectively, p < 0.038). There was no similarly significant difference between the senior residents and the orthopedic experts ([6.33 mm vs. 5.28 mm, respectively; p = 0.18). The senior residents achieved plunging depths of 5.17 mm at the end of the training session and 4.7 mm 2 weeks later compared to 7.14 mm at the end of the training session and 6 mm 2 weeks later for the junior residents. This study demonstrated the capability of a low-cost drilling simulator as a training model for reducing the plunging depth during the drilling of bone and soft tissue among junior and senior residents.

Background

The effect of corticosteroids on tendon properties is poorly understood, and current data are insufficient and conflicting. The objective of this study was to evaluate the effects of corticosteroids injection on intact and injured rotator cuff (RC) through biomechanical and radiographic analyses in a rat model.

Purpose: The purposes of this study were to examine factors that influenced the decision to repair a SLAP Type II lesion and to examine the difference between patients with and without a SLAP repair.

Method: Prospectively collected data of patients who had a SLAP Type II lesion were reviewed. Patients who had a repair were compared with those who did not have a clinical indication for repair. Disability outcome measures collected pre and 2 years post-operatively were the American Shoulder and Elbow Surgeons (ASES) and the Constant-Murley scores (CMS). Paired and independent t-tests and logistic regression were performed.

Results: One hundred and six patients (83 males, 23 females), mean age=50 (SD=14, range 18–81), with a SLAP Type II lesion were identified. Eleven patients (10%) had isolated SLAP pathology for which they received a repair. The remaining 95 (90%) patients had concurrent pathologies related to rotator cuff, instability, osteoarthritis, and other pathologies. Repair of the SLAP lesion was felt to be clinically indicated in 43(45%) of patients with combined lesions. Factors that influenced the decision to repair the SLAP lesion were age, nature of the associated pathology, the presence of a large or massive full thickness rotator cuff tear, anterior instability, and a partial biceps tear greater than 50% that required a tenodesis. Significant improvement was observed in the ASES and CMS scores (p < 0.0001) whether or not a SLAP repair was performed.

Conclusion: This study indicates that age and presence of certain associated pathologies influence the need for SLAP Type II repair. A statistically significant improvement in strength and disability level is observed in patients with SLAP Type II lesions associated with concomitant pathology, despite not having the SLAP lesion repaired. The indications for SLAP Type II repair in the presence of other pathologies are discussed.

The purpose of this historical prospective study was to compare the pre and post-operative Quality of Life (QOL) outcomes twelve months post-operatively in patients with partial thickness rotator cuff tears.

Data of ninety-three consecutive patients diagnosed with Partial Thickness Tear (PTT) who had undergone decompression, acromioplasty, or repair were used to compare the outcome between patients with Articular Tears (AT) and Bursal Tears (BT). The QOL outcome measures included one disease specific outcome measure, the Western Ontario Rotator Cuff Index (WORC) and two shoulder specific measures, the American Shoulder & Elbow Surgeons standardised shoulder assessment form (ASES) and the Constant-Murley score. A statistical paired t-test (pre vs. twelve months) and an independent t-test analysis (Articular vs. Bursal) were conducted to examine the impact of the tear site.

Forty-four Articular and forty-nine Bursal tears (forty-eight females and forty-five males) were included in the analysis. The mean age was 55.5 (SD: 13) and 53.3 (SD: 12) for the AT and BT groups respectively. There was no statistically significant difference between the two groups in pre-operative QOL outcome scores. Both groups showed significant improvement in the above outcomes (p< 0.0001) one year following surgery. However, the AT group was significantly less improved than the BT group in the post-op ASES scores (p=0.04), Constant-Murley scores (p=0.006) and WORC (p=0.01).

The intent of this study was to compare the pre and post operative scores and rate of improvement in two groups of patients suffering from rotator cuff pathology at different sites. The results indicate that the quality of life improves significantly regardless of the tear site. The pattern of recovery however is different indicating that patients with Bursal tears show a higher degree of improvement in their functional measures. The findings suggest that two types of tears are different in their etiology and pathomechanics.

Type II SLAP lesions account for 22–55% of all SLAP lesions and are described as detachment of the superior labrum along with the biceps anchor from the superior glenoid rim. This detachment may be associated with glenohumeral joint instability. The majority of SLAP lesions are associated with other pathologies such as rotator cuff tears, Bankart and other instability lesions. The purpose of this study was to evaluate the effectiveness of arthroscopic repair of type II SLAP lesions, two years following arthroscopic repair with suture anchors.

Data on thirty-eight consecutive patients (thirty-four males, four females, mean age: forty-five years, range, twenty-two to seventy years) were used for analysis. Outcome measures were the American Shoulder and Elbow Surgeons (ASES) assessment form and the Constant-Murley score. Thirteen patients had work-related injuries. Specific tests for SLAP lesion (i.e. New pain provocation test, O’Brien test, Yergason’s Test) were conducted pre-operatively.

Twenty-three patients had surgery on the right side. The O’Brien test was positive in 51% of the patients. The minimum follow up period was twenty-four months. Five patients had isolated SLAP type II lesion. Thirty-three had associated pathologies. Ten patients had rotator cuff repair. Twelve patients required acromioplasty and one patient underwent the long head of biceps tenodesis. Three patients had associated Bankart lesions. All patients showed significant improvement in ASES scores (p< 0.0001). However, Patients with work-related injuries did not show a significant improvement in Constant-Murley scores (p=0.20). Associated pathologies did not affect level of disability or subjective scores post-operatively. Strength did not change to a statistically significant level following SLAP repairs.

Arthroscopic SLAP repair provides significant improvement in subjective scores of the ASES. Patients with work-related injuries demonstrate a different pattern of recovery.

Introduction: Type II SLAP lesion account for 22–55% of all SLAP lesions and described as detachment of the superior labrum along with the biceps anchor from the superior glenoid rim. This detachment leads to a significant Gleno Humeral Joint instability at the anterior-posterior and superior inferior directions. Majority of SLAP lesions are associated with rotator cuff tears, and partial or complete Bankart lesions.

Purpose: The purpose of this study was to evaluate the effectiveness of arthroscopic repair of type II SLAP lesions 2 years following arthroscopic repair with suture anchors.

Type of study: Prospective historical.

Methods: Data of consecutive thirty-eight patients (34 males, 4 females, mean age: 45 years, range, 22 to 70 years were used for analysis. Outcome measures were the ASES and Constant Murley. Thirteen patients had work-related injuries. Specific tests for SLAP lesion (i.e. New pain provocation test, O’Brien test, Yergason’s Test) were conducted pre-operatively.

Results: Twenty-three patients had surgery on the right side. The minimum follow up period was 24 months. Five patients had isolated SLAP II lesion repair. Thirty-three had associated pathologies. Ten patients had rotator cuff repair. Twelve patients required acromioplasty and 12 patients underwent the long head of biceps tenodesis. Three patients had associated Bankart lesions. ALL patients showed significant improvement in ASES scores (p< 0.0001). However, Patients with work-related injuries did not show a significant improvement in Constant scores (p=0.20). Pathology did not affect level of disability or subjective scores post-operatively. Strength did not change following SLAP repairs.

Conclusions: Arthroscopic SLAP repair provides significant improvement in subjective scores of joint-specific measures (ASES). Patients with work-related injuries demonstrate a different pattern of recovery.

Purpose: The purpose of this historical prospective study was to compare the pre- and post-operative Quality of Life (QOL) outcomes 12 months post-operatively between Articular Tears (AT) and Bursal Tears (BT) of patients with partial thickness tear of the rotator cuff

Methods: Data of 93 consecutive patients diagnosed with Partial Thickness Tear (PTT) who had undergone decompression, acromiploasty, or repair were used to compare outcome between patients with Articular Tears and Bursal Tears. The QOL outcome measures included one disease specific outcome measure, the Western Ontario Rotator Cuff Index (WORC) and two shoulder specific measures, the American Shoulder & Elbow Surgeons standardized shoulder assessment form (ASES) and the Constant-Murley score. A statistical paired t-test (pre vs. 12 months) and an independent t-test analysis (Articular vs. Bursal) were conducted to examine the impact of the tear site.

Results: Forty-four Articular and 49 Bursal tears (48 females and 45 males) were included in the analysis. The mean age was 55.5 (SD: 13) and 53.3 (SD: 12) for the AT and BT groups respectively. There was no statistically significant difference between two groups in pre-operative QOL outcome scores. Both groups showed significant improvement in the above outcomes (p< 0.0001) one year following surgery. However, the AT group was significantly less improved than the BT group in the ASES scores (p=0.005), and Constant-Murley scores (p=0.035). The WORC was not sensitive in differentiating between the two groups (p=0.11).

Conclusion: The intent of this study was to compare the pre-operative and rate of improvement in two groups of patients suffering from different site of rotator cuff pathology. The results indicate that the quality of life improves significantly regardless of the tear site. The pattern of recovery however is different indicating that patients with Bursal tear show a higher degree of improvement in their functional measures, possibly due to reduced mechanical compression on rotator cuff.

Introduction: Latarjete operation for anterior shoulder instability, first described by Latarjete in 1954 consists of transfer of the coracoid process through the sub-scapularis tendon to the neck of the scapula. Many modifications were described in the English literature as described by Mc Murray in 1958, by Bonin in 1969 or May in 1970. In 1985, Braly and Tullos emphasized that the Bankart lesion, when present, should be corrected.

Rockwood transplants the entire coracoid process onto the neck by “laying it flat” onto the neck of the scapula using two screws instead of one, which gives a larger base for the coracoid transplant.

The disadvantages of this procedure, as described in the English literature, are relative shortening of the sub-scapularis tendon, thereby decreasing internal rotation power, limited external rotation and the possibility to damage the musculocutaneous nerve.

Purpose of the Study: To demonstrate that transplantation of the coracoid process with its tendon attachments through a split in the subscapularis muscle and tendon without shifting the capsula gives better results then transplant of the coracoid process with capsule-labral repair. The goal of this report is to review the result of our series.

Patients and Methods: Between January 2000 and June 2005, 26 Latarjete operations (Rockwood modification) were performed by the senior author. The indication for surgery was failed artroscopic Bankart repair or anterior shoulder instability associated with anterior inferior glenoid deficiencies (“inverted pear” deformity). Five cases were excluded having less than 6 months follow-up. In the first 5 cases in addition to the coracoid process transfer, labral repair with capsular shift was performed whereas in the next 21 cases only coracoid process transplant with excision of the damaged labrum/scar tissue and no capsular shift was performed. The postoperative rehabilitation program was the same for both groups. The patients age and sex was very close in both groups.

The parameters for comparison between the two groups were: range of motion, stability after 6 months, return to work and sport activity, satisfaction, and complication rate.

Results: 6 months after surgery all patients of both groups returned to full work and sport activity including contact sports. No recurrent dislocation was encountered during this short period of follow up. All patients who underwent this procedure, with or without capsule-labral repair, were satisfied with the procedure.

In the small group that included capsulo-labral repair an average of 10 degrees decrease of external rotation was encountered compared to the opposite shoulder. In the second group no decrease in range of motion was found.

Conclusion: Transfer of the coracoid process through the subscapularis tendon alone has better results then Latarjete operation complemented with capsulo-labral repair in regard of range of motion. The procedure is simple and of short duration giving the best solution for failed artroscopic procedures or for cases of shoulder instability having anterior inferior glenoid deficiencies.

The authors are aware that longer follow up is mandatory.

Introduction: In many cases of massive rotator cuff tears, especially in cases of revision repairs the shoulder surgeon is facing a technical and biological challenge. The loss of collagenous material in the tendon, coupled with poor quality of the remaining rotator cuff, makes obtaining a mechanically strong repair difficult. Primary closure of such defects may result in excessive tissue tension, which may further increase the chance of failure.

Purpose: The objective of this study is to determine the feasibility of using xenogeneic small intestine submucosa (SIS) as a biomaterial to reinforce repair of massive rotator cuff tears.

Clinical Material and Methods: Nine patients ranging in age from 52 to 74 with massive rotator cuff tears were selected for the study. Selection of these patients was based upon the quality of remaining rotator cuff tendon tissue at the time of the repair. Seven cases after failed repair of massive rotator cuff tear and two cases of long standing neglected rotator cuff tears in patients with weight bearing shoulders (bilateral below the knees amputation and incomplete paraplegia after anterior poliomyelitis) were selected for this study.

In all patients first the tear was repaired by well-known techniques: tendon to tendon, tendon to bone through bone tunnels or using suture anchors. After the repair was accomplished, the poor quality tissue obtained was reinforced by a patch of Restore Orthobiologic Soft Tissue Implant (DePuy, Johnson & Johnson). The Restore Implant is a xenograft obtained of ten layers of porcine small intestine submucosa, it is biocompatible, infection resistant, possess predictable mechanical properties, and, perhaps most significantly, induce a host connective and epithelial tissue response that results in regeneration of specialized connective tissues.

Results: Follow-up ranging between 6 to 22 month excellent and good results were observed in eight cases (88%), whereas in the patient aged 74, the cuff repair failed again (after two previous failures). In the eight successful cases an almost normal painfree active range of movements was observed three month after surgery.

Conclusions: The results confirm the usefulness of the SIS graft material in the patients having questionable quality cuff tissue remaining after repair. Use of the Restore soft tissue implant could possibly be utilized to strengthen the repair, as well as the inside ingrowth of the tendon, leading to a successful repair of the rotator cuff.

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.

Introduction: The increasing use of Arthroscopic surgery for recurrent anterior shoulder dislocations (RASD) has questioned the indications and contraindications for this procedure. The ideal candidate for this kind of surgery is an overhead athlete, who participates in a noncontact sport, with traumatic unidirectional anterior instability with a well-defined Bankart lesion.

Purpose of the paper: To demonstrate that complementing the Arthroscopic Bankart Repair (ABR) with an Arthroscopic Rotator Interval Closure (ARIC) the indication for Arthroscopic management of Anterior shoulder instability can be broaden for patients who has a less defined Bankart lesion and has additional multidirectional hyperlaxity.

Patients and Methods: Between January 1, 1999 and December 31, 2002, 166 patients (175 shoulders) suffering from recurrent anterior dislocations were treated by ABR. In the first two years, only patients who had unidirectional instability with no Hyperlaxity or grade 1 Hyperlaxity were selected for this specific method of treatment. Encouraged by the results, beginning of October 2001, in addition to the first group of patients we started to operate patients suffering of recurrent dislocations having grade 2 or grade 3 Hyperlaxity. In this second group of patients we added to the ABR an ARIC procedure. In the first group 130 shoulders whereas in the second group 45 shoulders were operated on. We used Panalok-Panacryl Smith and Nephew 3.5mm x2 Ethibond sutures (OBL) suture anchors or Bioknotless (Mitek) anchors. 157 cases had one side operated whereas in 9 cases both sides were operated on. There were 150 male patients and 16 females in these two groups, 91 patients had the left shoulder, 66 patients had the right shoulder and nine patients had both shoulders operated on. The mean follow-up was 3 years ranging between 4.5 to 1.7 years.

Results: In spite of the relatively short follow-up for the second group of patients we encountered very good preliminary results. At revision of all the cases we found 9 recurrences for the ABR group (representing 6.9%) in comparation of the one reoccurrence in the ABR supplemented by ARIC procedure (2.2%).

Conclusions: The ARIC is a new technique that broadens the indications for Arthroscopic shoulder surgery as a solution for recurrent dislocations associated with joint Hyperlaxity.

Introduction: Fractures of the proximal humerus account for 4–5% of all fractures. The number one cause of this type of fracture is age related osteoporosis associated with minimal trauma. Approximately 80% of these fractures are non or minimally-displaced, and can be treated conservatively with good results. However, treatment of displaced complex fractures is still controversial. The disadvantage of open procedures is the risk of damaging the blood supply to the humeral head, leading to a higher incidence of avascular necrosis.

Closed Reduction and Percutaneous Fixation (CRPF) is a minimal invasive procedure with a lower risk of damaging the blood supply. The main complication of this technique is loosening of the guide wires and displacement of the fragments requiring a second operation.

Purpose: The guide wire loosening leads us to improve the technique by adding an external fixator to stabilize the guide wires and secure fragment positioning. We report our experience of treating displaced fractures of the proximal humerus with Closed Reduction and External Fixation (CREF).

Materials and methods: Between the years 1996–2001 we operated on 37 patients for 38 complex fractures and fracture dislocations of the proximal humerus. We had 16 two part fractures, 13 three part fractures, 3 four part fractures, 5 two part fracture dislocation and 1 four part fracture dislocation according to the Neer’s classification.

The mean age was 60 years old ranging from 16–90 with a male to female ratio of 1:1. The patients were placed in a beach chair position using an image intensifier for AP and axillary views. Because the closed reduction was unsatisfactory, six patients underwent open reduction and external fixation. The remaining 32 shoulders underwent CREF.

Passive motion exercises were initiated on the first postoperative day. The external fixator was removed after four to six weeks (mean time for external fixator – 5.3 weeks). After removing the external fixator the patients began with active assisted mobilization of the shoulder and isometric strengthening exercises.

Results: The average follow up was 31.6 months (range 6–60 months). No loosening was observed upon removal of the external fixator, however the following complications were encountered: 5 patients had superficial pin tract infections, 1 patients developed an avascular necrosis of the humeral head, 1 patient had a non union of the fracture. Of the remaining patients, 13 patients had an excellent result, 15 patients had a good result and 5 patients had a fair result.

Conclusions: CREF is a minimal invasive technique for complex fractures of the proximal humerus, greatly reducing the damage to the blood supply when compared to open surgical procedures. It offers a better stabilization than CRPF, thus reducing the complication rate. The percutaneous technique causes less scaring and therefore a shorter rehabilitation program. Consequently, this procedure is recommended for complex fractures of the proximal humerus.