Bipolar Radiofrequency Ablation Does Not Result in Full-Thickness Articular Cartilage Penetration: An Ex Vivo Bovine Investigation.

Purpose: To evaluate the depth of penetration of manufacturer-recommended bipolar radiofrequency (BRF) output in healthy hyaline cartilage. Methods: Two matched knees from a bovine specimen were harvested for immediate testing. BRF probes were used to treat the articular cartilage in a hydrated noncontact technique employing a 1-mm spacer on patellar, condylar, and trochlear surfaces. Two manufacturer-recommended ablate power settings were evaluated to analyze the effect of varying power outputs on the depth of penetration. Surfaces were randomized and treated with BRF ablate setting 3 (AB-3), 4 (AB-4), or left untreated as a control (12 grids each). Slices were extracted from treatment zones and subjected to fluorescein diacetate and propidium iodide viability stains and analyzed with confocal light microscopy. A general linear model was used to determine whether variables such as ablation setting, cartilage location, and side significantly influenced depth of penetration (DoP) and cartilage thickness (Minitab 19, Chicago, IL). When significance was noted (P < .05), a post hoc-Tukey test was used to investigate specific differences. Results: AB-3 had a 50.9% lower mean DoP than AB-4 (P = .006). The mean DoP was 237.9 ± 140.6 µm for AB-3 and 484.1 ± 267.0 µm for AB-4. Median DoP values were 243.2 ± 149.5 µm for AB-3, 51.2% lower than the 498.4 ± 286.0 µm for AB-4. The mean maximum DoP for AB-3 was 302.4 ± 167.8 µm, 50.6% lower than AB-4 value of 611.6 ± 299.1 µm. Analysis of the cartilage thickness confirmed there was no difference in overall cartilage thickness used for AB-3 versus AB-4 testing (P = .953). Conclusions: The RF probe ablate power setting AB-3 demonstrated significantly less articular cartilage depth of penetration than the AB-4 setting in a healthy bovine model. Clinical Relevance: Debridement of chondral lesions with plasma BRF is of clinical interest. The presented study adds basic science information for those considering performing this technique.

The impact of solid organ transplant history on inpatient complications, mortality, length of stay, and cost for primary total shoulder arthroplasty admissions in the United States.

BACKGROUND: There is a growing population of patients with history of solid organ transplant (SOT) surgery among total joint patients. Patients with history of SOT have been found to have longer lengths of stay and higher inpatient hospital costs and complications rates after hip and knee arthroplasty. The purpose of this study was to determine whether this is true for shoulder arthroplasty in SOT patients. METHODS: The Nationwide Inpatient Sample was queried to describe relative demographic, hospital, and clinical characteristics, perioperative complications, length of stay, and total costs for patients with a history of SOT (International Classification of Diseases-9th Edition-Clinical Modificiation V42.0, V42.1, V42.7, V42.83) undergoing shoulder arthroplasty (81.80, 81.88) from 2004 to 2014. RESULTS: A weighted total of 843 patients (unweighted frequency = 171) and 382,773 patients (unweighted frequency = 77,534) with and without history of SOT, respectively, underwent shoulder arthroplasty. SOT patients were more often younger and more likely to be male, have Medicare, and undergo surgery in a large teaching institution in the Midwest or Northeast (P < .001). SOT patients had higher or similar comorbid disease prevalence for 27 of 29 Elixhauser comorbidities. The risk of any complication was significantly higher among SOT patients (15.5% vs. 9.3%, P = .007). SOT patients experienced inpatient admissions an average 0.27 days longer (P < .001) and $1103 more costly (P = .06) than non-SOT patients. CONCLUSIONS: Patients with history of SOT undergoing shoulder arthroplasty appear to remain a unique population due to their specific vulnerability to minor complications and inherently increased inpatient resource utilization.

Triceps Tendon Ruptures: A Systematic Review.

BACKGROUND: Triceps tendon ruptures (TTR) are an uncommon injury. The aim of this systematic review was to classify diagnostic signs, report outcomes and rerupture rates, and identify potential predisposing risk factors in all reported cases of surgical treated TTR. METHODS: A literature search collecting surgical treated cases of TTR was performed, identifying 175 articles, 40 of which met inclusion criteria, accounting for 262 patients. Data were pooled and analyzed focusing on medical comorbidities, presence of a fleck fracture on the preoperative lateral elbow x-ray film (Dunn-Kusnezov Sign [DKS]), outcomes, and rerupture rates. RESULTS: The average age of injury was 45.6 years. The average time from injury to day of surgery was 24 days while 10 patients had a delay in diagnosis of more than 1 month. Renal disease (10%) and anabolic steroid use (7%) were the 2 most common medical comorbidities. The DKS was present in 61% to 88% of cases on the lateral x-ray film. Postoperatively, 89% of patients returned to preinjury level of activity, and there was a 6% rerupture rate at an average follow-up of 34.6 months. The vast majority (81%) of the patients in this review underwent repair via suture fixation. CONCLUSIONS: TTR is an uncommon injury. Risks factors for rupture include renal disease and anabolic steroid use. Lateral elbow radiographs should be scrutinized for the DKS in patients with extension weakness. Outcomes are excellent following repair, and rates of rerupture are low.

Atypical Pectoralis Major Muscle Wasting in a Recreational Weight Lifter.

Pectoralis major injuries are relatively uncommon and can pose a diagnostic challenge. Deformity and weakness of this muscle in weight lifters is typically due to traumatic tendon rupture and often requires surgical repair. However, there are other less common etiologies that can mimic the clinical presentation of pectoralis major wasting and weakness that require different treatment approaches. This article describes a case of a 48-year-old recreational weight lifter who presented with severe pectoralis major wasting and weakness secondary to isolated mononeuropathy of the lateral pectoral nerve possibly due to Parsonage Turner syndrome. The patient was treated nonoperatively and achieved full recovery 18 months after onset. Parsonage Turner syndrome should be included in the differential diagnosis of patients with atraumatic weakness and wasting of the pectoralis major muscle and dysfunction. [Orthopedics. 2016; 39(4):e756-e759.].

Outcome After Arthroscopic Reconstruction of the Coracoclavicular Ligaments Using a Double-Bundle Coracoid Cerclage Technique.

PURPOSE: We report the outcome of an arthroscopic technique for coracoclavicular ligament reconstruction using an anatomic coracoid cerclage. METHODS: Between March 2011 and September 2012, 12 consecutive patients with symptomatic chronic (>4 weeks from injury) type V acromioclavicular separation for which nonoperative treatment failed were treated with arthroscopic double-bundle reconstruction of the coracoclavicular ligaments using tendon allograft by the first author. The clinical records, operative reports, and preoperative and follow-up radiographs were reviewed. The visual analog scale score, Subjective Shoulder Value, Simple Shoulder Test score, and Constant-Murley score were evaluated preoperatively and at each follow-up appointment. RESULTS: The study included 12 shoulders in 12 young active-duty soldiers with symptomatic high-grade acromioclavicular separation who were treated with a technique for arthroscopic reconstruction of the coracoclavicular ligaments. The mean age was 25 years (range, 20 to 35 years). The injury occurred during sports activity in 11 patients. One patient was injured in a motorcycle accident. The mean time from injury to surgery was 17.8 months (range, 1.5 to 72 months). The minimum length of follow-up was 24 months (mean, 30.4 months; range, 24 to 42 months). The mean preoperative and postoperative outcome scores were significantly different (P < .0001) for all subjective outcome measures. The mean Constant-Murley score improved from 58.4 (range, 51 to 76) to 96 (range, 88 to 100). The mean visual analog scale score improved from 8.1 (range, 7 to 10) to 0.58 (range, 0 to 2). The mean Subjective Shoulder Value improved from 32.9% (range, 10% to 70%) to 95% (range, 80% to 100%). The mean Simple Shoulder Test score improved from 6 (range, 5 to 8) to 11.83 (range, 11 to 12). All patients returned to their normal preinjury level of activity by 6 months. Radiographs at last follow-up showed no loss of reduction with maintenance of the coracoclavicular interval. There was 1 complication (8.5%), a postoperative superficial wound infection, that was treated accordingly. CONCLUSIONS: We present an arthroscopic technique for double-bundle tendon graft reconstruction of the coracoclavicular ligaments using the coracoid cerclage technique. This method showed good outcomes and maintenance of radiographic reduction with high patient satisfaction and a low complication rate. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Open reduction internal fixation of distal clavicle fracture with supplementary button coracoclavicular fixation.

Distal clavicle fractures are common, and no standard treatment exists. Many different surgical modalities exist. This report describes an open reduction internal fixation technique that achieves both plate and coracoclavicular stabilization using a button device. A precontoured superior-lateral plate is secured to the clavicle. A 3.2-mm spade-tipped drill bit is drilled across the clavicle and coracoid, passing through 4 cortices. The button is loaded onto an insertion device, passed across the 4 cortices, and captured on the undersurface of the coracoid under fluoroscopic guidance. This construct is linked to the distal clavicle plate by heavy sutures using a second button that sits in the plate. The lateral locking holes are then filled to finalize fixation. This technique provides for a simplified way to achieve coracoclavicular stabilization when using a plate for fixation of distal clavicle fractures.

Suprascapular neuropathy in a shoulder referral practice.

HYPOTHESIS: Suprascapular neuropathy (SSN) is considered a rare condition, and few studies have analyzed how commonly it is encountered in practice. Electrophysiologic studies are the gold standard for diagnosis; however, there is no consensus on diagnostic criteria. We hypothesized that SSN would be frequently diagnosed by electrophysiologic testing in a subset of patients with specific clinical and radiographic findings suggestive of the pathology. This study characterizes SSN in an academic shoulder referral practice and documents the electrodiagnostic findings that are currently being used to diagnose the condition. MATERIALS AND METHODS: A retrospective review of a 1-year period was used to identify all patients who completed electrodiagnostic studies to evaluate the suprascapular nerve. Clinical exam findings and associated shoulder pathology was documented. The specific electromyography (EMG) and nerve conduction studies (NCS) findings were analyzed. RESULTS: Electrodiagnostic results were available for 92 patients, and 40 (42%) had confirmed SSN. Patients with a massive rotator cuff tear were more likely to have an abnormal study than those without a tear (P = .006). The most common electrodiagnostic abnormalities were abnormal motor unit action potentials (88%), whereas only 33% had evidence of denervation. The average latency in studies reported as diagnostic of SSN was 2.90 ± 0.08 milliseconds for the supraspinatus and 3.78 ± 0.14 milliseconds for the infraspinatus. DISCUSSION: An electrodiagnostically confirmed diagnosis of SSN was seen in 4.3% of all new patients and in 43% of patients with clinical or radiographic suspicion of SSN. Clinical evaluation may be difficult because other shoulder pathology can have overlapping symptoms. CONCLUSION: Shoulder surgeons should consider electrophysiologic evaluation of patients with clinical or radiographic signs of SSN and be cognizant of the parameters that constitute an abnormal study.

Suprascapular neuropathy.

Suprascapular neuropathy has often been overlooked as a source of shoulder pain. The condition may be more common than once thought as it is being diagnosed more frequently. Etiologies for suprascapular neuropathy may include repetitive overhead activities, traction from a rotator cuff tear, and compression from a space-occupying lesion at the suprascapular or spinoglenoid notch. Magnetic resonance imaging is useful for visualizing space-occupying lesions, other pathological entities of the shoulder, and fatty infiltration of the rotator cuff. Electromyography and nerve conduction velocity studies remain the standard for diagnosis of suprascapular neuropathy; however, data on interobserver reliability are limited. Initial treatment of isolated suprascapular neuropathy is typically nonoperative, consisting of physical therapy, nonsteroidal anti-inflammatory drugs, and activity modification; however, open or arthroscopic operative intervention is warranted when there is extrinsic nerve compression or progressive pain and/or weakness. More clinical data are needed to determine if treatment of the primary offending etiology in cases of traction from a rotator cuff tear or compression from a cyst secondary to a labral tear is sufficient or whether concomitant decompression of the nerve is warranted for management of the neuropathy.

A prospective therapeutic comparison of simple suture repairs to massive cuff stitch repairs for treatment of small- and medium-sized rotator cuff tears.

PURPOSE: The purpose of this study was to compare the massive cuff stitch (MCS) with the simple stitch in terms of integrity at 2 years after surgery when used to repair small-sized to medium-sized full-thickness rotator cuff tears. METHODS: Seventy-one patients underwent arthroscopic repair of full-thickness rotator cuff tears between December 2004 and June 2006. The tear sizes ranged from 0.5 to 1.5 cm. The mean patient age was 53 years (range, 40 to 69 years), and the mean follow-up time was 33 months (range, 24 to 41 months). Group I (n = 35) underwent MCS repair, and group II (n = 36) underwent simple stitch repair. Results were analyzed by use of the Wilcoxon signed rank test and the Mann-Whitney test. Follow-up ultrasound was performed 24 to 41 months after repair. RESULTS: All patients showed improvements in the visual analog scale for pain, activities of daily living, and University of California, Los Angeles scores (P < .05), but there were no significant differences in scores between groups (P > .05). The satisfaction rating was similar for group I (4.7) and group II (4.3) (P > .05). The failure (retear) rate was significantly lower in group I (14.3%) than in group II (27.8%) (P < .05). CONCLUSIONS: The clinical outcomes between the MCS and simple stitch were not significantly different, but the MCS was superior to the simple stitch in maintaining repair integrity on ultrasound evaluation after arthroscopic repair of small-sized to medium-sized full-thickness rotator cuff tears. LEVEL OF EVIDENCE: Level III, prospective therapeutic comparative study.

Prevalence of cerebrovascular events during shoulder surgery and association with patient position.

The beach chair position is commonly used in both arthroscopic and open shoulder procedures. There has been recent concern that beach chair positioning may be an independent risk factor for intraoperative cerebrovascular insult, especially in concert with hypotensive anesthesia. We attempted to quantify the prevalence of intraoperative cerebrovascular events during shoulder surgery in the beach chair position. Two hundred and eighty-seven members of the American Shoulder and Elbow Surgeons (ASES) Society were e-mailed surveys, and 93 (32%) responded. The majority of these surgeons average >300 shoulder cases annually. Most of these cases are arthroscopic, and patient position is primarily beach chair. The total number of beach chair-position surgeries was estimated between 173,370 and 209,628, and lateral decubitus-position surgeries were estimated between 64,597 and 100,855. The overall rate of intraoperative cerebrovascular event was 0.00291% (8/274,225). All cerebrovascular events were associated with surgeries in the beach chair position. The rate in the beach chair position ranged from 0.00382% (8/209,628) to 0.00461% (8/173,370). If reported primary patient position was used > or = 75% of the time, no significant difference in observed cerebrovascular event rates was found between positions (P=.051-.0233). In relation to orthopedic procedures performed in the supine position, beach chair positioning does not appear to increase the risk of intraoperative cerebrovascular event.

Arthroscopic single-row supraspinatus tendon repair with a modified mattress locking stitch: a prospective, randomized controlled comparison with a simple stitch.

PURPOSE: Our purpose was to compare the clinical results and failure rates of arthroscopic rotator cuff repair by use of a modified mattress locking stitch (MMLS) repair versus a simple stitch repair. METHODS: Between December 2004 and January 2006, 78 cases of arthroscopically repaired full-thickness rotator cuff tears were evaluated prospectively. All tears were between 1.5 and 3 cm in size. The mean age of the patients was 53.4 years (range, 39 to 68 years), and the mean follow-up duration was 31.1 months (range, 24 to 37 months). Thirty-nine individuals underwent arthroscopic repair by use of an MMLS (group I). Thirty-nine individuals underwent arthroscopic repair by use of a simple stitch (group II). Postoperative visual analog scale scores for pain, scores for activities of daily living, and University of California, Los Angeles (UCLA) scores were obtained at a mean of 12 months (range, 6 to 36 months). We compared the results statistically by Mann-Whitney U test. In both groups magnetic resonance imaging scans were obtained at 6 to 36 months after repair. RESULTS: Between groups, the visual analog scale scores for pain, scores for activities of daily living, and University of California, Los Angeles scores were not significantly different (P > .05 for all). Of the patients, 92.3% in group I and 89.7% in group II showed excellent or good results at the final follow-up (P > .05). The satisfaction rate was 94.9% (37 cases) in group I and 89.7% (34 cases) in group II (P < .05). Radiographic failure was seen in 6 of 36 cases in group I (16.7%) and 9 of 30 cases in group II (27.4%) (P < .05). CONCLUSIONS: Arthroscopic repair of medium-sized (1.5- to 3-cm) full-thickness rotator cuff tears by use of an MMLS improves patient satisfaction rates and radiographic repair integrity in comparison to simple stitch repair. LEVEL OF EVIDENCE: Level II, lesser-quality randomized controlled trial.

Coracoclavicular stabilization using a suture anchor technique.

Multiple fixation options exist for coracoclavicular stabilization, but many are technically demanding and require hardware removal. In the study reported here, we reviewed a specific fixation technique that includes suture anchors moored in the base of the coracoid process. We retrospectively reviewed 24 consecutive cases of patients who underwent coracoclavicular stabilization with a suture anchor for a type III or type V acromioclavicular (AC) joint separation or a group II, type II or type V distal clavicle fracture. Eighteen of the 22 patients had full strength and painless range of motion (ROM) in the affected extremity by 3 months and at final follow-up (minimum, 24 months; mean, 39 months). Two patients were lost to follow-up. Four patients had early complications likely secondary to documented noncompliance. Two of these 4 patients underwent reoperation with a similar procedure and remained asymptomatic at a minimum follow-up of 15 months. One patient underwent osteophyte and knot excision 7 months after surgery and remained asymptomatic at 30 months. Our results suggest that coracoclavicular stabilization using a suture anchor technique is a safe and reliable method of treating acromioclavicular joint separations and certain distal clavicle fractures in the compliant patient.

Proximal biceps tendon: injuries and management.

The long head of the biceps tendon is a known pain generator of the shoulder. There are numerous pathologic entities that may affect this tendon, including tendonitis, partial tearing, and subluxation. These conditions are often associated with rotator cuff tears, especially those involving the subscapularis. Operative interventions include tenotomy and tenodesis. Tenodesis can be preformed in a proximal or distal location. Subpectoral tenodesis may have a lower recurrence rate than proximal-based techniques.