Arthroscopic removal of arch-shaped rotator cuff calcifying tendinitis without rotator cuff repair and acromioplasty is an excellent treatment regarding pain relief and function.

PURPOSE: The aim of this study is to evaluate clinical outcome for arthroscopic removal of calcium deposit without acromioplasty and rotator cuff repair for patients with ultrasound-diagnosed arch-shaped calcifying tendinitis of the rotator cuff (type I), homogenic (x-ray) with chronic pain. METHODS: We retrospectively reviewed 50 patients with homogenous, arch-shaped calcifying tendinitis, suffering from chronic pain and who underwent arthroscopic treatment and 50 patients with the same type of tendinitis treated conservatively. All patients had calcium deposit located in supraspinatus tendon, pre-operatively and post-operatively evaluated by ultrasound. Clinical outcome was assessed by using Quick DASH, UCLA, and VAS score. RESULTS: There were 29 male and 71 female patients; none had bilateral involvement. We divided patients into group A-operatively treated-and group B-conservatively treated-by shock wave therapy. Patients from group A had higher improvement of all used tests, QDash (from 19.3 to 2.7), UCLA (from 10 to 34), and VAS score (from 3 to 0) when compared with group B. CONCLUSION: Patients with arch-shaped calcium deposits and acoustic shadow have better results after arthroscopic treatment than the conservative one. There was no need for acromioplasty or tendon repair. The lack of performing the same did not have any impact on the post-operative rehabilitation and recovery.

CALCIFIC TENDINOPATHY: CALCIUM DEPOSIT MORPHOLOGY DIRECTLY AFFECTS PAIN AND FUNCTION OF THE SHOULDER.

The aim of this study was to determine conventional ultrasonography characteristics of calcium deposits in patients diagnosed with calcific tendinopathy, to determine vascularization around deposits by power Doppler, and to compare morphological and power Doppler findings with clinical findings by use of two questionnaires. Pain and function were evaluated using the visual analog scale and two questionnaires, Constant Shoulder Score and Oxford Shoulder Score. All subjects underwent ultrasonography examination and evaluation of vascularization (flow) along calcium deposit using power Doppler. Fifty-one subjects were included in the study. The χ2-test, a non-parametric statistics method was used because of the categorical type of variables. The level of statistical significance was set at p<0.05. In the inactive phase, calcium deposit was shown as a hyperechoic focal point with dorsal acoustic shadow and negative power Doppler finding, whereas in the resorptive phase it appeared as fragmented irregular hyperechoic focal points with positive power Doppler findings. This study showed the patients with fragmented, cloudy calcification to have statistically significantly worse results on functional questionnaires and more positive power Doppler findings (grades II and III) and to experience stronger pain (visual analog scale 8-10). Upon defining the stage of calcific tendinopathy, the method of treatment can be determined and further course of the disease predicted. Defining the stage of calcification precisely helps avoid unnecessary and long-lasting physical therapy while introducing an effective treatment option, depending on the stage of the disease.

Reverse shoulder arthroplasty in acute fractures provides better results than in revision procedures for fracture sequelae.

PURPOSE: The purpose of this study was to evaluate functional outcomes of reverse shoulder arthroplasty (RSA) in patients with acute fracture and sequelae of the proximal humeral fractures. METHODS: Thirty-seven patients were treated with RSA for acute fracture and sequelae of a proximal humeral fracture. The average age was 73 years (range 50-87 years). Twenty-one patients had had no previous surgery, seven patients had acute fractures and 14 patients had chronic fractures. Sixteen patients had had previous surgery. Active range of motion and Constant score were evaluated at a minimum follow-up of two years. RESULTS: Active elevation was 102°, external rotation 24°, and internal rotation was up to L4 in all patients. In the group of patients without previous surgery treated with RSA, elevation was 116°, external rotation 24°, and internal rotation up to L3. In the group of patients with previous surgery treated with RSA, elevation was 84°, external rotation 19°, and internal rotation up to L4. In the group of patients with acute fracture treated with RSA, elevation was 124°, external rotation 28°, and internal rotation up to L4. In the group of patients with chronic or sequel of the fractures treated with RSA elevation was 114° , external rotation 28°, and internal rotation up to L3. Constant score in all patients was 54. Constant score in patients without previous surgery treated with RSA was 68 and with previous surgery it was 42. CONCLUSION: Patients without previous surgery treated with RSA for fractures had better functional results than patients who had undergone previous surgery.

Functional results and patient satisfaction after arthroscopic capsular release of idiopathic and post-traumatic stiff shoulder.

PURPOSE: The purpose of this prospective study was to compare the functional results and patient satisfaction after arthroscopic shoulder capsular release in patients with idiopathic and posttraumatic stiff shoulder. METHODS: The study included 50 patients who underwent arthroscopic capsular release after failure of conservative treatment. The etiology of stiffness was either idiopathic (25 patients) or post-traumatic (25 patients). There were 28 women and 22 men with an average age of 49 years (range, 32-70 years). All patients were treated with physical therapy for a mean of six months (range, 3-12 months) before surgery. Range of motion was measured three times: 48 hours after surgery, then one month and six months after surgery. RESULTS: Constant score showed improvement for both groups of patients in the period of six months after surgery. In the group with idiopathic stiffness the score increased from 36 to 86, while in the group with post-traumatic stiff shoulder the score advanced from 32 to 91. The idiopathic stiff shoulder group had an improved active forward flexion from 90 to 161°, external rotation from 10 to 40°, and internal rotation from L5 to L1. In the post-traumatic stiff shoulder groupthe forward flexion was improved from 95 to 170°, external rotation from 13 to 40° and internal rotation from L4 to L1. CONCLUSION: There was an improvement of range of motions and patients' satisfaction after arthroscopic shoulder capsular release and manipulation under anesthesia, equally in idiopathic and post-traumatic stiff shoulder, compared to the situation before surgery. Post-traumatic contracture patients expressed higher level of satisfaction with their shoulder function than the idiopathic stiff shoulder patients.

Arthroscopic transosseous suture anchor technique for rotator cuff repairs.

The skin is incised 1 to 2 cm distal to the lateral portal. A transosseous tunnel is created through the greater tuberosity by a sharp penetrator, entering 1.5 to 2 cm distal to the top of the greater tuberosity. The penetrator exits medially, between the tip of the greater tuberosity and the articular surface of the humeral head, in the middle of the footprint. The first anchor, a 5-mm Spiralok (DePuy Mitek, Norwood, MA) is placed at the penetrator's exit site on the footprint. Using a specially designed suture leader, the lateral limb of the suture in the anchor, which passes through the previously created transosseous tunnel, is taken from the anchor and pulled out. The other suture end is passed through the supraspinatus tendon. The second suture, placed superficially in the anchor, is passed from the anchor through the supraspinatus tendon, as a mattress suture. If more anchors are required, the procedure should be repeated. The transosseous suture limb and the suture limb that is passed through the supraspinatus tendon are tied through the lateral portal. The knot tying is then performed with a sliding Delimar knot. The mattress suture, passing through the supraspinatus tendon, is tied through the anterior lateral portal. The knot tying procedure is repeated depending on the number of anchors.

Arthroscopic extracapsular plication to treat multidirectional instability of the shoulder.

Successful arthroscopic treatment of multidirectional shoulder instability requires that the surgeon reduce the volume of the capsule. This goal can be achieved by using the extracapsular plication technique. There are several advantages to using pancapsular plication and an intra-articular knot. Much better potential for capsular healing exists when the outer layer of the capsule, which is composed of fibrous tissue, is tied extra-articularly. With the intra-articular plication technique, the inner layer of the capsule is synovia, which has less healing capacity. The amount of capsule plication that can be achieved with the extra-articular plication technique exceeds what is possible with the intra-articular plication technique. This is very important in patients who have a large degree of instability in the anterior, the posterior, and, particularly, the inferior direction. Thermal capsulorrhaphy enhances other arthroscopic stabilization procedures. Thermal striping helps to reduce capsular redundancy if laxity persists. However, with arthroscopic extracapsular plication, the capsular tissue can be shortened without using thermal energy.

[Emergencies in shoulder joint surgery]. / Hitna stanja u ortopedskoj kirurgiji ramena.

Emergency in orthopaedics compared to classical surgery presents a completely different issue. Some orthopaedic conditions do not require immediate surgery, but they have to be solved within weeks or months, and are therefore addressed as relatively urgent conditions. If this kind of surgery is delayed, condition may deteriorate, and in some cases it becomes impossible to perform reconstructive surgical procedure. Considering this, some shoulder conditions require urgent and some relatively urgent surgery. When time limits are concerned that means these patients have to be operated on within 3 to 6 weeks, or during first three months after the initial trauma.

Functional and electromyographic results after open rotator cuff repair.

Fifty-one patients treated for full-thickness rotator cuff tears were followed up an average of 4 years after surgery (range, 2-6.4 years). The shoulder function was assessed according to the Constant classification, each patient did strength measurements, and had electromyographic evaluation of the supraspinatus and infraspinatus muscles. The mean value of the Constant score for the surgically treated shoulder was 2.7 points. Forty-five patients (88.2%) had satisfactory scores and six patients (11.8%) had unsatisfactory scores. The result of treatment was significantly correlated to the size of the tear and the time elapsed from injury to surgery. However, no correlation was found between the result of the treatment and the type of surgery, mode of postoperative rehabilitation, and age. The strength measurement of abduction and of external rotation indicated significantly reduced power in surgically treated shoulders compared with contralateral shoulders. There was a significant difference of the infraspinatus motor unit potential interference pattern reduction between surgically treated and the contralateral shoulder. There was a positive correlation between electromyographic findings and the results of rotator cuff reconstruction.

[Rotator cuff rupture]. / Rupture rotatorne manzete.

The rotator cuff is the complex of four muscles that arise from the scapula; supscapularis, supraspinatus, infraspinatus and teres minor. The long head of the biceps tendon may be considered a functional part of the rotator cuff. The rotator cuff is key structure of the shoulder which gives dynamic stability and movements. Rotator cuff tears my occur as consequence of impingement syndrome or degenerative changes. Most tears occur in the supraspinatus tendon. The patients are usually older than 40 years. On clinical examination there is weakness of abducation and external rotation of the arm. Open or arthroscopic repair should be performed in active individuals.

Acetabular roof reconstruction with pedicled iliac graft.

Reconstruction of the acetabular roof in patients with hip dysplasia shows disappointing mid-term results due to insufficient incorporation and collapse of the bone graft. We have developed a new reconstructive method using a pedicled iliac graft. We simulated surgical reconstruction of the acetabular roof in ten cadaver specimens. The purpose was to evaluate whether the deep circumflex artery was long enough to allow transfer of the graft without requiring micro-vascular anastomosis. In all cadavers, the length of the pedicle was sufficient to reach any desired position of the acetabular roof. The use of such a pedicled structural graft may provide good primary stability and allow local bony remodelling and incorporation under load.

Fully arthroscopic stabilization of the patella.

The authors present a new fully arthroscopic technique for the treatment of patellofemoral instability consisting of plication of the medial patellar retinaculum and release of the lateral patellar retinaculum. The indication for this procedure is not only acute patellar luxation, but also recurrent patellar luxation and subluxation. The procedure has been performed on 17 patients, 6 male and 11 female, between the ages of 14 and 27 years. The indication for surgical arthroscopic treatment was patellar instability in 3 patients, acute patellar luxation in 4, and recurrent patellar luxation in 10 patients. Postoperative results after follow-up of 12 to 26 months have been good with no recurrence of subluxation or luxation. This procedure is a valuable technique for treating patellar maltracking and instability and acute and recurrent patellar luxation, particularly in adolescents and young adults.