Topographical measurement of the attachments of the central band of the interosseous membrane on interosseous crests of the radius and ulna.

BACKGROUND: To suggest a reasonable isometric point based on the anatomical consistency of interosseous membrane (IOM) attachment in association with topographic characteristics of the interosseous crests, the footprints of the central band (CB) of the IOM on the radial and ulnar interosseous crests (RIC and UIC) were measured. METHODS: We measured the distance from the CB footprints from each apex of both interosseous crests in 14 cadavers and the angles between the forearm axis of rotation (AOR) and the distal slopes of the RIC and UIC in 33 volunteers. RESULTS: The CB footprints lay on the downslope of both interosseous crests with its upper margin on average 3-mm proximal from the RIC's apex consistently in the radial length, showing normality (p>0.05), and on average 16-mm distal from the UIC's apex on the ulna without satisfying normality (p<0.05). The average angle between the UIC's distal slope and the AOR was 1.3°, and the RIC's distal slope to the AOR was 14.0°, satisfying the normality tests (p>0.05), and there was no side-to-side difference in both forearms (p<0.05). CONCLUSIONS: The CB attached to the downslope just distal to the RIC's apex constrains the radius to the UIC that coincides with the AOR of the forearm circumduction, maintaining itself both isometrically and isotonically.

Scapular and humeral elevation coordination patterns used before vs. after Reverse Total Shoulder Arthroplasty.

The purpose of this study was to compare scapulohumeral coordination used before and after Reverse Total Shoulder Arthroplasty (RTSA) during the ascent phase of scapular plane arm elevation tasks performed with varied shoulder rotations (neutral, external rotation, and internal rotation). We expected that after RTSA, participants would decrease scapulothoracic upward rotation angular displacement and increase the scapulohumeral rhythm (SHR) vs. before RTSA. 11 RTSA patients (12 shoulders) participated in this study before and after RTSA while optical motion capture measured kinematics of the humerus and scapula relative to the thorax. Angular kinematics were compared pre vs. post-RTSA within-participant using One Dimensional Statistical Parametric Mapping (SPM) t-tests (α = 0.05) and across-participants, using paired t-tests (α = 0.05) adjusted for multiple comparisons. As a group, during arm elevation with neutral rotation, the mean (SD) SHR pre-RTSA was 1.5 (0.5) and increased to 1.7 (0.3) post-RTSA, though, not significantly (p = 0.182). In contrast, during arm elevation with external rotation, the mean (SD) SHR pre-RTSA was 1.3 (0.4) and significantly increased (p = 0.018) post-RTSA to 1.7 (0.3). Likewise, during arm elevation with internal rotation, the mean (SD) SHR pre-RTSA was 1.2 (0.3) and significantly increased (p < 0.001) post-RTSA to 1.7 (0.2). In addition to these and other group trends, participant-specific patterns were uncovered through SPM analyses - with some participants significantly increasing and others significantly decreasing scapulothoracic angular displacements across humerothoracic elevation ranges. Both before and after RTSA, scapulohumeral rhythm ratios were within the range of those previously reported in post-RTSA patients and were smaller than those used by healthy populations.

Subscapularis pyomyositis presenting as shoulder stiffness mistaken as frozen shoulder in young female: a case report.

Pyomyositis of the shoulder region in young healthy patients is rare but can lead to fatal overwhelming sepsis. Here we present the case of an otherwise healthy 32-year-old female patient with pain and stiffness in the right shoulder. Initial treatment with physical therapy and injection was ineffective. Magnetic resonance imaging of the right shoulder suggested subscapularis intramuscular sarcoma but excision of the muscle and biopsy revealed organized subscapularis pyomyositis. This case demonstrates the importance of investigating predisposing conditions in young patients with painful stiffness mimicking frozen shoulder that does not respond to nonoperative treatment.

Patient-specificity of scapular orientation measurements using an acromion marker cluster with multiple calibration poses.

The purpose of this study was to understand how each calibration pose affects scapular orientations measured by an Acromion Marker Cluster during scapular plane arm elevation performed by patients who had been pre-operatively indicated for Reverse Total Shoulder Arthroplasty. Eight pre-operative Reverse Total Shoulder Arthroplasty patients participated in this study while optical motion capture measured kinematics, specifically scapulothoracic angles and angular displacements, vs. humerothoracic elevation. The angle measurements were compared across the static calibration poses used to calculate them within-patient with One Dimensional Statistical Parametric Mapping paired t-tests and across-patients with a series of Sign Tests. The study uncovered patient-specificity in the effects of the Acromion Marker Cluster calibration pose on scapulothoracic angles and near linear offsets between the scapulothoracic upward rotation angles. The scapulothoracic upward rotation angular displacement measurements across calibration poses were within 5° of each other, suggesting nearly linear offsets between upward rotation angle measurements from each calibration pose. The Sign Tests revealed that using the Neutral calibration pose estimated significantly greater scapulothoracic protraction angles during arm elevation than did using the Hand to Back Pocket calibration pose (p = 0.02). Scapulothoracic protraction and posterior tilt measurements were near linear offsets between calibration poses only when humerothoracic elevation was less than 50°. Results encourage patient-specific and humerothoracic elevation-specific methods to combine calibration poses and the development of standards to report scapulothoracic orientations derived from using an Acromion Marker Cluster with multiple calibration poses.

Editorial Commentary: Perianchor Cysts-We Need More Worries After Rotator Cuff Repair Like We Need Holes in the Head.

Cysts or radiolucent rings are relatively common around suture anchors after rotator cuff repair. The rate of cyst occurrence is similar across anchor types and materials. Generally, perianchor cysts are benign and can be regarded as not affecting clinical outcomes.

Management of Ulnar Collateral Ligament Injuries in Overhead Athletes.

Ulnar collateral ligament injuries of the elbow are frequent among overhead athletes. The incidence of ulnar collateral ligament reconstructions (UCLRs) in high-level players has increased dramatically over the past decade, but the optimal technique of UCLR is controversial. Surgeons need to manage the patients' expectations appropriately when considering the mode of treatment. This article reviews current studies on the management of ulnar collateral ligament injuries, particularly in overhead athletes.

Arthroscopic percutaneous inverted mattress suture fixation of isolated greater tuberosity fracture of humerus.

OBJECTIVE: The purpose of the study was to evaluate the clinical and radiographic outcomes of treatment in patients with isolated greater tuberosity (GT) fractures of humerus using arthroscopic percutaneous inverted mattress suture fixation technique. MATERIALS AND METHODS: We attempted to use the arthroscopic percutaneous inverted mattress suture fixation technique in 17 consecutive cases with isolated displaced GT fractures. Fourteen patients were successfully treated without switching to other methods and were available for follow-up at a mean of 22 months (range: 17-38 months) after surgery. For assessment of clinical outcomes, we evaluated the range of motion and the visual analog scale (VAS) score, the shoulder index of the American Shoulder and Elbow Surgeons (ASES), and the Korean Shoulder Scale (KSS). RESULTS: At the final follow-up, the VAS improved to 1.0 points (range: 0-3), the mean ASES score improved to 86.9 points (range: 78.3-100) and the KSS improved to 88.6 points (range: 82-100) postoperatively. Mean union time was 10 weeks. Mean forward flexion was 167.8° (range: 140-180°), mean external rotation in neutral position was 36° (range: 20-70°), and mean internal rotation was at the 12th thoracic level (range: T6-L3) at final follow-up. Three cases were switched to open surgery after attempted arthroscopic technique due to large fragment or osteoporosis. CONCLUSION: In select cases, the arthroscopic percutaneous inverted mattress suture fixation of GT fracture is a simple and reproducible technique with encouraging early results.

Radiolucent rings around bioabsorbable anchors after rotator cuff repair are not associated with clinical outcomes.

PURPOSE: Various researchers have observed small areas of osteolysis after using bioabsorbable anchors in shoulder surgeries. The purpose of this study is to determine whether radiographic perianchor radiolucent rings after rotator cuff repair are associated with the failure of repair and also assess their clinical implications. Further, the most frequent location of the radiolucent rings in the double-row suture bridge configuration was also assessed. METHODS: One hundred and twenty-nine consecutive patients who underwent arthroscopic rotator cuff repair by suture bridge technique were retrospectively evaluated radiographically and clinically. The number and size of the rings that appeared at each follow-up were recorded. Also, the locations of each ring were recorded as anterior, middle or posterior, and medial or lateral according to the construct of the anchors used for suture bridge technique. The size of the tear, the number of anchors used and age of the patients were compared. Re-tear rates according to ultrasound examinations were also analyzed. RESULTS: After rotator cuff repair, the mean American Shoulder and Elbow Surgeons (ASES) score increased from 46.7 to 88.0 and the overall re-tear rate was 8.5% (11 cases). Seventy-three patients (56.6%) showed RR (total number of 99 rings) at least once during the course of their follow-up and the rings appeared at a mean period of 18.2 months after surgery. Mean size of the rings initially was 5.6 mm and the rings increased or decreased in mean size of 0.4 mm during mean follow-up of 37 months. No correlation was seen with the number of RRs and the rate of re-tears, number of anchors, size of tears, and clinical outcome as determined by the ASES score. Radiolucent ring measurement reproducibility was confirmed by independent, repeated measurements. The rings appeared mostly at anteromedial anchors (75 rings, 75.8%) and the authors suggest that mechanical factors may play a role for the cause of radiolucent rings. CONCLUSIONS: The number and the size of RRs around bioabsorbable anchors after rotator cuff repair do not appear to adversely affect the healing and clinical outcome of ARCR. Most radiolucent rings appeared at anteromedial anchors, indicating that mechanical factors may play a role for the radiolucencies. LEVEL OF EVIDENCE: Case series, level IV.

Feasibility of Hip Fracture Surgery Using a No Transfusion Protocol in Elderly Patients: A Propensity Score-Matched Cohort Study.

OBJECTIVES: To determine whether hip fracture surgery (HFS) without transfusion affects postoperative mortality and complications in elderly patients. DESIGN: Retrospective comparative study. PATIENTS: Three hundred fourteen patients ≥65 years of age who underwent HFS between May 2003 and December 2014. Patients were divided into 2 groups: those who consented to blood transfusion if needed and those who did not. One-to-one propensity score matching generated 50 matched pairs of patients. INTERVENTION: Patients underwent HFS with or without blood transfusion. In the no transfusion group, simultaneous administration of erythropoietin and iron was used as an alternative. MAIN OUTCOME MEASUREMENTS: The primary outcome was postoperative mortality (90-day, 1-year, overall). The secondary outcomes were hemoglobin change and the incidence of postoperative complications. RESULTS: HFS using a no transfusion protocol was not associated with increased mortality at any time point. Mean hemoglobin levels were significantly different between the 2 groups on postoperative day 1 (11.0 ± 1.3 vs. 10.5 ± 1.6, P = 0.002) but levels completely recovered within 2 weeks in both groups. There was also no difference in postoperative complication rates between the 2 groups, and overall hospital stays and charges were similar. CONCLUSIONS: An HFS protocol without blood transfusion was not associated with increased mortality or complications in elderly patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictive factors associated with failure of nonoperative treatment of superior labrum anterior-posterior tears.

BACKGROUND: Uncertainty remains in the natural course of superior labrum anterior-posterior (SLAP) tears treated conservatively with rehabilitation and activity modification. Our purpose was to evaluate clinical outcomes after nonoperative treatment of type II SLAP tear in young active patients and to identify factors related to negative outcomes. METHODS: We retrospectively reviewed 63 patients who initially underwent nonoperative treatment for isolated type II SLAP tear. Assessments were made at baseline and at 6 months, and telephone survey was used to evaluate the final outcome. All included patients underwent a consistent nonoperative treatment protocol, and patient-specific data on the outcome were assessed. Failure was defined as abandonment of nonoperative management for surgery at any time points, <20-point improvement in American Shoulder and Elbow Surgeons score at final follow-up, or inability to return to activities. RESULTS: At the average follow-up of 21 months, pain relief and function improved significantly (American Shoulder and Elbow Surgeons score, 54.2-86.4; Visual Analog Scale score, 4.6-1.7; P < .05) in 45 patients (71.4%) with successful nonoperative treatment. Eighteen patients (28.5%) were either dissatisfied with treatment or had arthroscopic surgery and were considered a failure group. Multivariate analysis showed that failure of nonoperative treatment is strongly linked with history of trauma, positive compression-rotation test result, and participation in overhead activities (P < .05). CONCLUSIONS: An initial trial of nonoperative management may be considered in young active patients with isolated SLAP tear. Patients with history of trauma, mechanical symptoms, and demand for overhead activities are less likely to succeed.

Functional performance tests as indicators of returning to sports after anterior cruciate ligament reconstruction.

BACKGROUND: There is a lack of standardized objective criteria to accurately assess the ability of a patient to progress through the end stages of rehabilitation and safely return to their previous level of athletic activity after anterior cruciate ligament (ACL) reconstruction. PURPOSE: To determine objective factors involved in returning to sports following ACL reconstruction. METHODS: Based on our inclusion criteria of a minimum 2-year follow-up, pre-injury sports activity level of Tegner 5 or greater, we retrospectively evaluated 67 patients who underwent ACL reconstruction. The patients were divided into "return-to-sports" (n=51) and "non-return" groups (n=16) by surveying participants using a questionnaire. Comparisons between the two groups were made using pre-operative and post-operative International Knee Documentation Committee questionnaires (IKDC), Lysholm score, and KT-2000 arthrometer. Flexor and extensor muscle strength, and functional performance tests (one-leg-hop test, co-contraction, shuttle run, and carioca tests) were used for assessment. RESULTS: Overall clinical results, including IKDC score, Lysholm score, and KT-2000 arthrometer, improved in all patients post-operatively and no significant difference was seen between the two groups (P>0.05). Although there was no significant difference in flexor or extensor deficits, one-leg-hop test, or shuttle run test, "return-to-sports" group obtained significantly better scores in the co-contraction and carioca tests (P<0.05). CONCLUSIONS: Tests that assess rotational stability showed statistically significant differences between the two groups. Further prospective studies with larger cohort are needed to determine the factors associated with returning to sports after ACL reconstruction. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

Arthroscopic inside-out repair of complete radial tears of the meniscus with a fibrin clot.

PURPOSE: To report on the results of 12 complete radial tears of the meniscus treated using arthroscopic inside-out repair with fibrin clots, the results showed good meniscal healing and excellent clinical outcomes. METHODS: From 2007 to 2009, 12 patients with complete radial tears of the meniscus were treated by arthroscopic inside-out repair with fibrin clots. In all patients, the International Knee Documentation Committee (IKDC) subjective knee form and Lysholm score were determined pre- and post-operatively. We performed magnetic resonance imaging (MRI) and if indicated, we performed a second-look arthroscopic examination. RESULTS: At a mean of 30 ± 4 postoperative months, the Lysholm score and IKDC subjective knee score had improved from 65 ± 6 and 57 ± 7 to 94 ± 3 and 92 ± 3, respectively. Eleven of 12 cases showed complete healing on follow-up MRI. Six of 7 patients undergoing a second-look arthroscopic examination had healed completely. CONCLUSION: This study shows successful meniscal repairs using fibrin clots in complete radial tears. This surgical procedure appears to be a good treatment method for complete radial tear of the meniscus. LEVEL OF EVIDENCE: Case series, level IV.

Meniscus root refixation technique using a modified Mason-Allen stitch.

A complete posterior medial meniscus root tear results in the inability to withstand hoop stress and requires the repair of the posterior medial meniscus root. Several techniques to repair the posterior medial meniscus root have been proposed, but most techniques are based on simple stitching. A modified Mason-Allen technique, recognized as a superior stitching method to repair rotator cuff in shoulder surgery, was applied to overcome the potential weakness of those simple stitching techniques. This newly modified Mason-Allen technique reproduces the locking effect of a conventional modified Mason-Allen stitch allowing the physiological meniscal extrusion. The purpose of this article is to describe a posterior root repair technique using a modified Mason-Allen stitch with two strands consisting of a simple horizontal and a simple vertical stitch. Level of evidence V.

Reducing the size of the meniscal allograft decreases the percentage of extrusion after meniscal allograft transplantation.

PURPOSE: The purpose was to evaluate the amount of extrusion and clinical and radiographic outcomes of meniscal allograft transplantation (MAT) after use of a modified Pollard method to measure the size of the meniscus. METHODS: We analyzed 36 patients who underwent MAT between September 2002 and June 2008. Eighteen patients had preoperative allograft sizing by the conventional Pollard sizing method, and the other 18 had the size measured by our modified method, reducing the total size of the graft by 5% from the Pollard method. The mean follow-up period was 31.4 months (range, 24 to 36 months). We compared the absolute amount of extrusion and the relative percentage of extrusion between the 2 groups. We also compared the Lysholm knee score, amount of joint space narrowing on radiographs, and Kellgren-Lawrence grade. RESULTS: The absolute amount of extrusion did not differ significantly between the 2 groups. However, the mean relative percentage of extrusion was lower in the modified Pollard group (P = .037). The mean Lysholm knee score increased in all patients, but there was no significant difference between the 2 groups. There was no significant difference in terms of radiographic outcomes. CONCLUSIONS: Reducing the graft size by 5% from the Pollard method decreases the percentage of meniscal extrusion after MAT without any adverse outcome clinically or radiographically. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Fibrin clot delivery system for meniscal repair.

As meniscal preservation particularly in younger active individuals with a symptomatic meniscal tear remains the preferred treatment option, various methods have been suggested to increase healing and success rates after meniscal repair. The recent increase in clinical use of platelet rich plasma has contributed to the increased use of fibrin clot, which virtually has the same healing property. However, despite the relative ease of acquisition and preparation of fibrin clots, delivering it to the desired target area arthroscopically is challenging. Therefore, we report with a pertinent literature review a novel method of planting a fibrin clot to the desired area of meniscal tear arthroscopically using our delivery system to enhance healing.