Effect of Preoperative Frozen Shoulder on Clinical Outcomes After Arthroscopic Rotator Cuff Repair.

BACKGROUND: A concomitant rotator cuff tear (RCT) with frozen shoulder is a common but challenging clinical scenario. The effect of frozen shoulder on clinical outcomes is open to discussion. PURPOSE/HYPOTHESIS: This study aimed to evaluate the effect of preoperative frozen shoulder on postoperative clinical outcomes of an RCT. We hypothesized that the treatment results of an RCT concomitant with preoperative frozen shoulder would be comparable with those of an isolated RCT. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 212 patients were divided into 2 groups: 154 in the non-frozen shoulder (NFS) group and 58 in the preoperative frozen shoulder (FS) group. All patients underwent a thorough preoperative evaluation that included range of motion (ROM) and the pain visual analog scale, functional visual analog scale, Constant score, and American Shoulder and Elbow Surgeons (ASES) score. The same evaluation was performed at 6 months and 1 and 2 years postoperatively. The healing status of the repaired RCT of all patients was evaluated by postoperative magnetic resonance imaging. RESULTS: The FS group showed statistically significantly worse functional outcomes than the NFS group at 6 months and 1 year postoperatively (P < .05). At 2 years postoperatively, active assisted ROM was equivalent between the groups, although the ASES and Constant scores were significantly lower for the FS group (P < .033 and P < .001, respectively). The retear rates were 5.3% and 12.3% for the FS and NFS groups, respectively (P = .013). CONCLUSION: Preoperative frozen shoulder positively affected rotator cuff healing but negatively affected most functional outcomes, including ROM, at 6 months and 1 year postoperatively. At 2 years after surgery, there was no significant difference in active motion, but outcome scores remained lower in the FS group. For patients with preoperative frozen shoulder, a delay in surgery for additional physical therapy might not be necessary. The retear rate for the NFS group was more than double that for the FS group in the current study, which indicates that surgery for an RCT combined with frozen shoulder might provide better results in the long term because of an intact, healed rotator cuff.

Reversibility of Supraspinatus Muscle Atrophy in Tendon-Bone Healing After Arthroscopic Rotator Cuff Repair.

BACKGROUND: To date, there are few reports of the definite reversibility of rotator cuff muscle atrophy after repair. PURPOSE: To evaluate the reversibility of rotator cuff muscle atrophy after successful arthroscopic repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Included in this study were 47 patients (mean age, 61.2 ± 7.3 years; range, 49-73 years) who underwent arthroscopic rotator cuff repair as well as magnetic resonance imaging (MRI) preoperatively and at 6-month and last follow-up. Patients who had confirmed rotator cuff healing (grades 1-3 according to the Sugaya classification) on both series of postoperative MRI were enrolled in the study. The mean time from the onset of symptoms to surgery was 24.7 ± 25.6 months (range, 3-120 months). The minimum follow-up was 2 years, and the mean follow-up duration was 41.8 ± 14.4 months. Serial changes in the supraspinatus muscle area on the most matching MRI scans (sagittal-oblique view) were evaluated. The area was measured by 2 independent observers. RESULTS: Both independent observers reported no significant difference in the area of the supraspinatus muscle between the preoperative time point and 6-month follow-up (observer 1: P = .135; observer 2: P = .189). However, there was a significant difference between the 6-month and last follow-up (mean, 41.8 months; observers 1 and 2: P < .001). The serial changes in the area preoperatively and at 6-month and last follow-up were 419.41 ± 122.97 mm(2), 431.76 ± 104.27 mm(2), and 466.73 ± 121.42 mm(2), respectively (observer 1), and 421.01 ± 116.61 mm(2), 432.56 ± 100.78 mm(2), and 469.84 ± 113.80 mm(2), respectively (observer 2). The intraclass correlation coefficient between the 2 observers was 0.988. At final follow-up, the area increase on the medial and lateral aspects of the sagittal-oblique view compared with preoperatively was 13.9% (P < .001) and 11.3% (P < .001), respectively. Fatty infiltration did not change from preoperatively to 6-month follow-up (P > .999) or from 6-month to final follow-up (P = .077). CONCLUSION: After successful arthroscopic rotator cuff repair, there was a slight (11.3%-13.9%) increase in muscle volume from preoperatively to final follow-up, as seen on serial MRI. Fatty infiltration according to the Goutallier grade was not reversed (P = .077). Some reversibility of supraspinatus muscle atrophy may exist in tendon-bone healing after arthroscopic rotator cuff repair; further follow-up is needed to better elucidate this result.

Can ulnar variance be used to detect overstuffing after radial head arthroplasty?

BACKGROUND: Overstuffing of the radiocapitellar joint during metallic radial head arthroplasty has been reported to cause loss of elbow flexion, capitellar erosion, and early-onset osteoarthritis. Although this is known, there is no agreed-on measurement approach to determine whether overstuffing has occurred. QUESTIONS/PURPOSES: We therefore hypothesized that overlengthening the radial head during radial head arthroplasty changes the ulnar variance in the wrist. METHODS: Seven cadaveric radii were implanted with radial head prostheses of increasing thickness. Each specimen was implanted successively with increasingly thick radial head prostheses measuring 2, 4, and 6 mm thicker than the native radial head, and radiographs were taken after implantation of each prosthesis. The ulnar variance with each prosthesis was measured using the method of perpendiculars. RESULTS: The ulnar variance of the native and 2-mm (p = 0.04), 4-mm (p = 0.008), and 6-mm (p = 0.008) overly thick radial head prosthesis-implanted states decreased significantly with each incremental increase in prosthetic head thickness. CONCLUSIONS: Implantation of thicker radial head prostheses decreased the ulnar variance. Our results indicate ulnar variance could be used to detect overstuffing of radial head prostheses. CLINICAL RELEVANCE: The simplicity and reliability of ulnar variance make it a potentially useful indicator of overlengthening after radial head arthroplasty.

Brain stem hypoplasia associated with Cri-du-Chat syndrome.

Cri-du-Chat syndrome, also called the 5p-syndrome, is a rare genetic abnormality, and only few cases have been reported on its brain MRI findings. We describe the magnetic resonance imaging findings of a 1-year-old girl with Cri-du-Chat syndrome who showed brain stem hypoplasia, particularly in the pons, with normal cerebellum and diffuse hypoplasia of the cerebral hemispheres. We suggest that Cri-du-Chat syndrome chould be suspected in children with brain stem hypoplasia, particularly for those with high-pitched cries.

Subtrochanteric valgus osteotomy with monolateral external fixator in hips for patients with severe cerebral palsy.

Subtrochanteric valgus osteotomy has been used for painful hip joint dislocation in patients with severe cerebral palsy. The goal of this study was to evaluate 11 patients (17 hips) with severe cerebral palsy who had chronically dislocated and painful hips treated with subtrochanteric valgus osteotomy using a monolateral external fixator. A retrospective review was performed of 11 patients (average age, 17.8 years) with severe quadriplegic cerebral palsy with flexion-adduction contractures due to chronically dislocated and painful hips. A subtrochanteric valgus osteotomy with a monolateral fixator was performed in all patients. Patients were analyzed clinicoradiologically, and caregivers were asked about ease of handling, transfers, and perineal care. At an average follow-up of 37 months (range, 14-72 months), all caregivers were satisfied with the surgery and felt that their child was more comfortable and could sit with support for a longer time period and that perineal care, wheelchair mobilization, and transfers were much easier. A total of 11 complications in 7 patients were observed, including pin-tract infections, delayed consolidation, abduction deformity, and hypostatic pneumonia. The complication rate of subtrochanteric valgus osteotomy was comparable with other methods, and this method had the advantage of shorter surgical time, ease of application, no internal implant with lesser chance of infection or heterotopic calcification, and less intraoperative blood loss with less morbidity.

Serial bone mineral density ratio measurement for fixator removal in tibia distraction osteogenesis and need of a supportive method using the pixel value ratio.

Distraction osteogenesis is one of the common procedures for limb lengthening. However, attempts are being made constantly to establish objective guidelines for early and safe removal of a fixator using a sensitive and quantitative measurement technique. Dual-energy X-ray absorptiometry (DEXA) has been evaluated in the past for understanding callus stiffness, and the present study is a step further in this direction. The purpose of this study was to evaluate the correlation between bone mineral density ratio (BMDR) obtained by a DEXA scan and the pixel value ratio (PVR) on plain digital radiographs at each cortex and various callus pathways and callus shapes as described by Ru-Li's classification. A retrospective analysis of 40 tibial segments in 23 patients operated upon for various indications for limb lengthening was carried out. There were 11 male and 12 female patients with a mean age of 18 years. The Ilizarov method was applied after monofocal osteotomy, and distraction and consolidation were monitored using digital radiographs and DEXA scanning. BMDR was positively correlated with PVR, and the optimal BMDR for removal of the fixator was found to be 0.511. PVR of all cortices, except the anterior cortex, showed significant positive correlation with BMDR of the regenerate. There was good correlation between BMDR and PVR in the homogenous or heterogenous pathway according to callus shape and pathway. Thus, this study shows that BMD measurement can provide an objective and noninvasive method for assessing the rate of new bone formation during tibial distraction osteogenesis. It can thus function as an effective adjunct to measure callus stiffness, along with PVR, using digital radiographs, especially in cases in which callus maturation and stiffness is doubtful. Further studies especially dealing with callus progression through the lucent pathway as well as those dealing with regenerate fractures may be needed to conclusively prove the efficacy of this method for measurement of callus maturation.

Pelvic support osteotomy for unstable hips using hybrid external fixator: case series and review of literature.

BACKGROUND: Instability of the hip joint is a source of great discomfort to the patient due to pain, limp and leg-length discrepancy. Pelvic support osteotomy with Ilizarov hip reconstruction, along with its various modifications, has emerged as a standard treatment modality for this difficult problem. We present a series of patients with unstable hips treated with a modification of the monolateral fixator-the hybrid external fixator. MATERIALS AND METHODS: A retrospective review of a series of 23 patients (38 hips) with unstable hips treated at our institute with the hybrid external fixator was performed. The mean age of the patients was 19.1 years (range 7-49 years). The outcomes were evaluated radiologically and clinically using the Harris hip score. RESULTS: After a mean follow-up period of 30.5 months (range 10-91 months), the range of motion of the hip had improved, pain had decreased, and the Harris hip score had improved from 63.43 to 75.17, which was statistically significant. The pre-operative knee range of motion was achieved in all patients by the last follow-up. Trendelenburg gait disappeared in all patients except for 3, limb length discrepancy improved from a pre-operative mean of 43 mm to a post-operative mean of 5 mm at final follow-up, and the mechanical axis was regained in all patients. Pin-tract infections were the commonest complications, occurring in 12 patients (52%). CONCLUSIONS: This study shows that pelvic support osteotomy using the new hybrid external fixator, which combines the versatility and modularity of the Ilizarov frame with the compactness of the monolateral fixator, is a useful treatment modality in individuals with unstable hips.