Acromioclavicular joint separation: Controversies and treatment algorithm.

In this article, we present an uptodate outline of acromioclavicular (AC) joint separation. A clear understanding of acromioclavicular joint injury in terms of the mechanism of injury, clinical picture, diagnostic imaging, and most updated surgical techniques used for the treatment can provide the best care for those patients. This article describes updated treatment strategies for AC separation, including type III AC separation which is known most controversial. Finally, we present a proposed treatment algorithm that can aid in the treatment of AC separation from the most updated evidence.

Pectoralis Major Rupture: Evaluation and Management.

Pectoralis major tendon ruptures are being reported with increasing frequency and primarily occur in young, high demand, male patients. The injury results from an eccentric contracture of the muscle most commonly while performing the bench press maneuver during weight training. In the setting of both acute and chronic injury, physical examination is critical for a timely and accurate diagnosis. During physical examination, comparison with the opposite side is imperative, and findings may include swelling, ecchymosis, loss of the anterior axillary fold, and a decreased pectoralis major index. Surgical treatment of acute ruptures is superior to nonsurgical treatment and results in improved functional outcomes and high levels of return to work and sport. Repair of chronic tears is more challenging and may require reconstruction with autograft or allograft tissue. Despite advances in surgical technique, tendon rerupture, persistent pain, and wound infection remain a concern.

Incisional paresthesia following clavicle plate fixation: does it matter to patients?

BACKGROUND: Operative management of clavicle fractures is increasingly common. In the context of explaining the risks and benefits of surgery, understanding the impact of incisional numbness as it relates to the patient experience is key to shared decision making. This study aims to determine the prevalence, extent, and recovery of sensory changes associated with supraclavicular nerve injury after open reduction and plate internal fixation of middle or lateral clavicle shaft fractures. METHODS: Eighty-six patients were identified retrospectively and completed a patient experience survey assessing sensory symptoms, perceived post-operative function, and satisfaction. Correlations between demographic factors and outcomes, as well as subgroup analyses were completed to identify factors impacting patient satisfaction. RESULTS: Ninety percent of patients experienced sensory changes post-operatively. Numbness was the most common symptom (64%) and complete resolution occurred in 32% of patients over an average of 19 months. Patients who experienced burning were less satisfied overall with the outcome of their surgery whereas those who were informed of the risk of sensory changes pre-operatively were more satisfied overall. CONCLUSIONS: Post-operative sensory disturbance is common. While most patients improve, some symptoms persist in the majority of patients without significant negative effects on satisfaction. Patients should always be advised of the risk of persistent sensory alterations around the surgical site to increase the likelihood of their satisfaction post-operatively.

Bilateral Arthroscopic Superior Capsular Reconstruction of the Shoulder for Irreparable Rotator Cuff Tears: A Case Report and Description of Surgical Technique.

The treatment strategies for rotator cuff tears have grown more sophisticated in recent years. Over the past decade, arthroscopic superior capsular reconstruction (SCR) has become popular for treating irreparable rotator cuff tears. Despite the popularity, the literature on the clinical outcomes of SCR is limited. Several surgical procedures using variable graft materials and different techniques have been proposed promising early clinical results with improvements in shoulder pain, range of motion, and overall function. In this paper, we present a case of bilateral massive irreparable rotator cuff tears, with a full description of our surgical technique and the successful outcome of our management.

Distal Biceps Tendon Tears: Diagnosis and Treatment Algorithm.

¼: Distal biceps tendon (DBT) tears occur most commonly in middle-aged men after a sudden, forced eccentric contraction of the flexed elbow. ¼: An understanding of the multiple risk factors, mechanisms, and pathophysiological causes is essential for proper and timely diagnosis. ¼: High clinical suspicion and routine physical examination with appropriate special examination tests, including the hook test, the passive forearm pronation test, the biceps crease interval test, and the bicipital aponeurosis flex test, can help with rapid and accurate diagnosis and guide appropriate and timely management. ¼: Treatment for DBT tears depends on the extent (complete versus incomplete) and timing (acute versus chronic) of the injury, and options include nonoperative management, repair, and reconstruction with or without repair of the bicipital aponeurosis.

Pectoralis Major Ruptures: Tear Patterns and Patient Demographic Characteristics.

BACKGROUND: The pectoralis major (PM) is made up of multilaminar muscle segments that form a complex insertion on the proximal humerus; it is composed of an anterior and a posterior tendon layer. The tear patterns and patient characteristics of operatively treated PM ruptures in the general population remain poorly understood. PURPOSE: To comprehensively report the demographic characteristics of patients who are clinically diagnosed with structurally significant PM ruptures and to describe PM tear patterns identified during surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective analysis of surgically treated PM tears was performed for a single-surgeon case series between January 1, 2003, and November 1, 2017. Patient demographic characteristics, classification of tear pattern, and treatment (repair/reconstruction) were recorded. RESULTS: A total of 104 surgical cases of PM tendon rupture were identified; 100 patients underwent primary repair and 4 underwent dermal allograft reconstruction. All patients were male, with a mean age of 36.5 ± 9.2 years. Chronic tears (>6 weeks old) accounted for 63.6% of surgical cases, and 96% (n = 100) of tears occurred at or between the musculotendinous junction and tendinous insertion. A partial-thickness, complete-width tear of the posterior tendon layer at this same location was the most common tear pattern identified. CONCLUSION: PM ruptures occurred almost exclusively at or between the musculotendinous junction and tendinous insertion, with predominant involvement of the posterior tendon layer. Chronic tears can be safely treated with primary repair in the vast majority of cases.

Outcome of Distal Biceps Tendon Repair With and Without Concomitant Bicipital Aponeurosis Repair.

BACKGROUND: The bicipital aponeurosis (BA) can often be torn concomitantly with a distal biceps tendon (DBT) rupture. Its repair, although recommended by some, has not commonly been addressed during the surgical management of DBT ruptures, and to date, surgical repair of the BA with DBT repair has not been evaluated clinically. PURPOSE: To utilize subjective and objective outcome measures to examine the safety and efficacy of 2-incision DBT repair with and without repair of the BA in patients with a DBT rupture. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Demographic and surgical data were reviewed retrospectively. Patients returned to the clinic to complete subjective outcome measures and objective measurements of range of motion, strength, and biceps contour. All patients were evaluated at least 1 year after surgical treatment. RESULTS: Data from 24 male patients with a DBT rupture were used for the analysis; 13 (54%) underwent concomitant DBT and BA repair, and 11 (46%) underwent isolated DBT repair. There were no complications at 1 year in either group. The DBT + BA repair group returned to recreational activities faster (77% within 6 months and 100% within 1 year) than the isolated DBT repair group (36% within 6 months, 91% within 1 year, and 100% after more than 2 years) (P = .05). There was a trend toward better Patient-Rated Elbow Evaluation pain scores in the DBT + BA repair group than in the isolated DBT repair group (1.2 vs 5.3, respectively; P = .18). A trend also emerged toward closer return to subjective preinjury strength (77% vs 44%, respectively; P = .14). No significant difference emerged in patient satisfaction with the biceps contour, subjective scores on functional activities and disability, or objective measurements of strength, contour, and range of motion. CONCLUSION: This pilot study suggests that repair of the BA in conjunction with DBT repair leads to a faster return to recreational activities compared with isolated DBT repair. Also noted was a trend toward subjectively improved pain and greater perceived strength, after DBT + BA repair, although this was not statistically significant. Further investigation with a larger population is required to better elucidate these potential differences.

Abnormal Pain Response After a Compensable Shoulder Injury.

BACKGROUND: The role of psychosocial factors has been established in patients with shoulder abnormalities. However, the prevalence of exaggerated pain behaviors and their association with the characteristics of injured workers have not been well studied. PURPOSE: To examine the prevalence of abnormal pain responses (APRs) in workers with active workers' compensation claims for a shoulder injury and to examine the differences between workers with APRs versus workers without APRs. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: An analysis of electronic data files of injured workers was completed. An APR was defined as an exaggerated pain response during a clinical examination, including facial grimacing, shaking, withdrawal, nonanatomic dermatome or myotome disturbances, increased tenderness, regional symptoms, and verbal utterances such as groaning, moaning, or gasping. To control for potential confounders, patients with positive APRs (APR group) were matched with injured workers without APRs (control group) seen in the same clinic and matched for sex, age, and surgical candidacy. RESULTS: Data from 1000 workers who had sustained a shoulder injury at work and who were referred for an early assessment by an orthopaedic surgeon and a physical therapist were reviewed. A total of 86 (9%) injured workers (mean age, 47 ± 11 years; 55 [64%] female) demonstrated APRs and were matched with 86 injured workers without APRs. There were no statistically significant between-group differences in the wait time, mechanism of injury, coexisting comorbidity, type of abnormality, or medication consumption. The APR group reported higher levels of disability (P < .0001) and psychological problems (P < .0001), presented with more inconsistency in range of motion (P = .04), and had more limitations at work (P = .02). CONCLUSION: The presence of an APR after a compensable shoulder injury was associated with higher reports of disability and psychological problems. Patients with positive APRs were more likely to be off work and less likely to perform full duties.

Sex and gender disparity in pathology, disability, referral pattern, and wait time for surgery in workers with shoulder injury.

BACKGROUND: The role of sex as an important biological determinant of vulnerability to sustaining injury and gender as a social determinate of access to resources, referral for medical care and perceived disability remains conflicted in injured workers. The purpose of this study was to examine sex and gender disparity following a compensable work-related shoulder injury. METHODS: This study involved cross-sectional analyses of data of two independent samples of workers with shoulder injury. Measures of disability and pain were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Numerical Pain Rating Scale (NPRS) for patients seen at an Early Shoulder Physician Assessment (ESPA) program and the American Shoulder and Elbow Surgeons (ASES) assessment form and Visual Analogue Scale (VAS) for the sample who underwent surgery. RESULTS: The files of 1000 (443 females, 557 men) consecutive patients seen at an ESPA program and 150 (44 females, and 106 men) consecutive patients who underwent rotator cuff surgery (repair or decompression) were reviewed. Significant gender disparity was observed in the referral pattern of injured workers seen at the ESPA program who were referred for surgical consultation (22 vs. 78 % for females and males respectively, p < 0.0001). The independent rotator cuff surgical group had a similar gender discrepancy (29 % vs. 71 %, p < 0.0001). The timeframe from injury to surgery was longer in women in the surgical group (p = 0.01). As well, women waited longer from the date of consent to date of surgery (p = 0.04). Women had higher incidence of repetitive injuries (p = 0.01) with men reporting higher incidence of falls (p = 0.01). Women seen at the ESPA program were more disabled than men (p = 0.02). Women in both samples had a higher rate of medication consumption than men (p = 0.01 to <0.0001). Men seen at the ESPA program had a higher prevalence of full thickness rotator cuff tears (p < 0.0001) and labral pathology (p = 0.01). However, these pathologies did not explain gender disparity in the subsample of ESPA who were referred for surgical consultation or those who had surgery. CONCLUSIONS: Sex and gender disparity exists in workers with shoulder injuries and is evident in the mechanism of injury, perceived disability, medication consumption, referral pattern, and wait time for surgery.

Accuracy of magnetic resonance imaging in detecting biceps pathology in patients with rotator cuff disorders: comparison with arthroscopy.

BACKGROUND: There is limited information on the validity of magnetic resonance imaging (MRI) in detection of biceps disease. The purpose of this study was to examine the measurement properties of noncontrasted MRI in diagnosis of biceps disease using arthroscopic surgery as the "gold standard." MATERIALS AND METHODS: Prospectively collected surgical data of patients with impingement syndrome or rotator cuff tear, with biceps disease (study group) or without biceps disease (control group), were reviewed. MRI reports of radiologists with fellowship training in musculoskeletal imaging were retrospectively reviewed and compared with surgical findings. RESULTS: Data of 183 (130 study and 53 control) patients (73 women [40%], 110 men [60%]; mean age, 62 years [standard deviation, 9]) who had undergone arthroscopic rotator cuff-related surgery during a period of 11 years were used for analysis. Sensitivity and specificity of MRI for detection of full tears of the biceps tendon were 0.54 and 0.98, respectively. Sensitivity and specificity were 0.27 and 0.86 for partial tears of the biceps tendon, respectively. For biceps subluxation or dislocation, sensitivity was 1.00 and specificity was 0.83. The areas under the receiver operating characteristic curves, which quantify the overall accuracy of the tests, were 0.57, 0.75, and 0.92 for partial tear, full tear, and instability of the biceps tendon, respectively. CONCLUSIONS: Noncontrasted MRI has a low sensitivity and high specificity for detection of full-thickness tears of the biceps tendon. It is highly sensitive for diagnosis of instability of the long head of the biceps. However, its usefulness for diagnosis of partial tears of the biceps tendon remains limited.

Short-Term Effectiveness of Precut Kinesiology Tape Versus an NSAID as Adjuvant Treatment to Exercise for Subacromial Impingement: A Randomized Controlled Trial.

OBJECTIVE: To compare the short-term effectiveness of precut kinesiology tape (PCT) to a nonsteroidal anti-inflammatory drug (NSAID) as adjuvant treatment to exercise physiotherapy in improving pain and function in patients with shoulder impingement. DESIGN: Randomized, controlled assessor-blind parallel-design trial with 3 groups. SETTING: Academic-community hospital. PATIENTS: One hundred patients (mean age: 48 ± 12.3, 61 men, 39 women) with a diagnosis of subacromial impingement (SAI) syndrome were randomized to a treatment group from October 2009 to June 2012. Eighty-one patients completed the study. INTERVENTIONS: Patients were randomized to one of the 3 treatment groups: PCT and Exercise (n = 33), NSAID and Exercise (n = 29), or Exercise only (n = 38) for a 4 session 2-week intervention with a registered physiotherapist. MAIN OUTCOME MEASURES: Numeric pain rating scales for pain at rest and pain with arm elevation, the Simple Shoulder Test (SST), and the Constant Score were assessed pretreatment and post-treatment. RESULTS: A statistically significant reduction in pain at rest and pain with arm elevation, as well as improvement in SST and Constant Score were observed in all 3 treatment groups, with minimal clinically important differences shown on pain with elevation and SST scores. Between-group differences on all outcome measures were not statistically significant or clinically meaningful. CONCLUSIONS: The improvements in pain and function observed with an NSAID or PCT as adjuvant treatments were no greater than with rehabilitation exercise alone. If adjuvant treatment is desired, PCT seems to be better tolerated than an NSAID, although the difference did not reach significance. CLINICAL RELEVANCE: The routine addition of adjuvant treatment is not supported by the results of this study. As adjuvant therapy, PCT seems to be better tolerated than an NSAID. If desired, clinicians may consider incorporating PCT along with an exercise component in the conservative treatment of SAI syndrome.

Unrecognized Isolated Medial Trochlear Fracture Leading to Malunion: A Case Report.

CASE: A twenty-year-old woman presented with an isolated intra-articular fracture of the medial part of the trochlea twelve weeks after a traumatic fall. The fracture had gone undetected during the initial twelve weeks following injury, resulting in an anteriorly and superiorly displaced malunion and severe range-of-motion restrictions of the elbow. CONCLUSION: Vigilant clinical examination is imperative to avoid missing this uncommon fracture pattern and complication. Prompt surgical management is necessary to ensure that adequate healing is achieved and to avoid unnecessary complications. This case report demonstrates that an excellent clinical outcome can be achieved with intra-articular osteotomy and anatomic fixation of the malunited segment.

A 3-Dimensional Anatomic Study of the Distal Biceps Tendon: Implications for Surgical Repair and Reconstruction.

BACKGROUND: Complete rupture of the distal biceps tendon from its osseous attachment is most often treated with operative intervention. Knowledge of the overall tendon morphology as well as the orientation of the collagenous fibers throughout the musculotendinous junction are key to intraoperative decision making and surgical technique in both the acute and chronic setting. Unfortunately, there is little information available in the literature. PURPOSE: To comprehensively describe the morphology of the distal biceps tendon. STUDY DESIGN: Descriptive laboratory study. METHODS: The distal biceps terminal musculature, musculotendinous junction, and tendon were digitized in 10 cadaveric specimens and data reconstructed using 3-dimensional modeling. RESULTS: The average length, width, and thickness of the external distal biceps tendon were found to be 63.0, 6.0, and 3.0 mm, respectively. A unique expansion of the tendon fibers within the distal muscle was characterized, creating a thick collagenous network along the central component between the long and short heads. CONCLUSION: This study documents the morphologic parameters of the native distal biceps tendon. Reconstruction may be necessary, especially in chronic distal biceps tendon ruptures, if the remaining tendon morphology is significantly compromised compared with the native distal biceps tendon. Knowledge of normal anatomical distal biceps tendon parameters may also guide the selection of a substitute graft with similar morphological characteristics. CLINICAL RELEVANCE: A thorough description of distal biceps tendon morphology is important to guide intraoperative decision making between primary repair and reconstruction and to better select the most appropriate graft. The detailed description of the tendinous expansion into the muscle may provide insight into better graft-weaving and suture-grasping techniques to maximize proximal graft incorporation.

Venous thromboembolism after shoulder arthroplasty: a report of three cases.

Venous thromboembolism after shoulder arthroplasty is considered a rare phenomenon, but can be a dangerous and life-threatening condition. We report three cases of venous thromboembolism sustained after shoulder arthroplasty. One of the patients had a non-fatal pulmonary embolism. The other two had deep vein thrombosis, one in the operated upper extremity, and the other in a lower extremity. The cases are described in detail and discussed to reveal the possible contributing risk factors. The purpose of this case series is to increase awareness of this relatively rare, but potentially serious complication.

Outcome of distal clavicle resection in patients with acromioclavicular joint osteoarthritis and full-thickness rotator cuff tear.

PURPOSE: The purpose of this study was to examine the impact of distal clavicle resection (DCR) on subjective and objective outcome measures in patients with acromioclavicular (AC) joint osteoarthritis (OA) and rotator cuff tear. METHODS: Prospectively collected data of consecutive patients with arthroscopic evidence of OA of the ACJ with complete data at 2 years were used for the data analysis. Patients with moderate-to-severe OA of the AC joint underwent a DCR in conjunction with rotator cuff repair, while patients with mild OA of the ACJ underwent surgery related to concomitant rotator cuff tear without a DCR. RESULTS: Data of 184 (72 females, 112 males, mean age: 62) patients with rotator cuff tear and varying degrees of OA of the AC joint were used for the analysis. Of 184 patients, 144 (78 %) had a resection of distal clavicle (resection group) and 40 (22 %) did not have a resection (no-resection group). Both groups showed a statistically significant (p < 0.0001) improvement in the American Shoulder and Elbow Surgeons (ASES) scores, Constant Murley score, and strength. Multivariable analysis showed that lower pre-operative ASES scores (higher disability), having a larger tear, an active compensation claim, and not having a DCR, had a negative impact on post-operative ASES scores. CONCLUSION: When untreated surgically, even mild arthroscopic findings of AC joint OA may lead to a poorer outcome after rotator cuff repair. Further characterisation of patients in whom mild arthroscopic findings of OA of AC joint are clinically significant and warrant resection is needed. LEVEL OF EVIDENCE: Retrospective outcome study, Level II.

Venous thromboembolism after shoulder arthroplasty: a systematic review.

BACKGROUND: Shoulder arthroplasty (SA) is a common orthopaedic procedure that is being performed on a more and more frequent basis. Venous thromboembolism (VTE) as a complication has received little attention when it occurs after SA. The literature lacks a comprehensive summary of the incidence, risk factors, and prophylaxis of VTE in this population of patients. METHODS: Literature on VTE after SA has been identified from 5 scientific databases: EMBASE, MEDLINE, Web of Science, CINAHL, and Cochrane. All primary full-text articles reporting at least 1 case of deep vein thrombosis or pulmonary embolism after SA were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, thromboprophylaxis, diagnosis, and management of VTE after SA. RESULTS: This study included 14 articles. The reported incidence of VTE after SA was 0.2% to 16.0%. The most serious risk factors for development of VTE included history of VTE, thrombophilia, major surgery, advanced age, current malignant disease, immobility, and bed confinement. Diagnosis was typically determined by duplex scan and chest computed tomography scan. VTE prophylaxis was used in 6 (43%) of the included studies, with the ideal method of prophylaxis unknown. CONCLUSIONS: Although variability exists in the reported incidence of VTE, surgeons should still be aware of the potential for this serious complication after SA. We recommend assessing the risk factors and estimating the VTE risk status for all patients undergoing SA. The ideal method of prophylaxis for this population of patients remains unknown and should be investigated in future high-quality clinical studies.

Improving the rapid and reliable diagnosis of complete distal biceps tendon rupture: a nuanced approach to the clinical examination.

BACKGROUND: Diagnosis of complete distal biceps tendon rupture (DBTR) is frequently missed or delayed on clinical examination. No single clinical test, including MRI, has demonstrated 100% efficacy in assessing the integrity of the distal biceps tendon. HYPOTHESIS: Combining 3 validated clinical tests for identifying complete rupture can maximize a true-positive diagnosis for complete DBTR without the need for confirmatory soft tissue imaging when performed in concert with other important factors from the history and clinical examination. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: The hook test, the passive forearm pronation (PFP) test, and the biceps crease interval (BCI) test were applied in sequence in conjunction with a standard patient history and physical examination on 48 patients with suspected distal biceps tendon injuries. If results on all 3 special tests were positive for complete rupture, the patient was referred for surgical repair; diagnosis was confirmed intraoperatively. If results on all 3 special tests were negative, diagnosis was confirmed with soft tissue imaging and patients were managed nonoperatively. If results of the 3 tests were not in agreement, soft tissue imaging was used to clarify the disagreement and to confirm the diagnosis. RESULTS: Thirty-five patients had unequivocal results based on history, physical examination, and special tests. Thirty-two tested in agreement positive for complete rupture, which were confirmed intraoperatively. Three tested in agreement negative, with subsequent imaging confirming partial rupture. Thirteen patients had equivocal special test results; soft tissue imaging suggested complete rupture in 10 and partial rupture in 3. CONCLUSION: Application in sequence of the hook test, the PFP test, and the BCI test results in 100% sensitivity and specificity when the outcomes on all 3 special tests are in agreement.