Recovery of active external rotation and elevation in young active men with irreparable posterosuperior rotator cuff tear using arthroscopically assisted latissimus dorsi transfer.

BACKGROUND: Massive irreparable posterosuperior rotator cuff tears represent a serious functional disablement for young and active patients in their daily activities. Latissimus dorsi (LD) muscle-tendon transfer can restore elevation and external rotation where supraspinatus and infraspinatus function is lost. MATERIALS AND METHODS: Between 2009 and 2013, 45 consecutive patients underwent arthroscopically assisted LD transfer for an irreparable posterosuperior rotator cuff tear. Thirty-three patients agreed to participate in this retrospective study. For 8 patients, we used a standard passage of the LD through the plane between the infraspinatus-teres minor and the deltoid muscles. For the remaining 25 patients, we transferred the LD tendon in front of the triceps muscle according to a personal described technique. The follow-up period was 35.7 months. Final follow-up included assessment by standard radiographs, bipolar surface electromyography, pain score by visual analog scale, Constant-Murley shoulder score, and Disabilities of the Arm, Shoulder, and Hand score. For quantitative strength evaluation measurements, a Biodex dynamometer was used. RESULTS: Overall clinical outcomes improved at the final follow-up and were significantly age related. We found similar results for revision and primary patients with mean increase in Constant-Murley scores of 29.5 and 30.5 points, respectively. In our series, we recorded osteoarthritis progression in 33.3% of patients. CONCLUSION: Arthroscopic LD tendon transfer for irreparable posterosuperior rotator cuff tears can achieve good clinical outcomes at a midterm follow-up, especially in active men 60 years of age or younger and in patients with low preoperative elevation (<80°) but an intact or reparable subscapularis tendon.

Reliability of forced internal rotation and active internal rotation to assess lateral instability of the biceps pulley.

PURPOSE: the aim of this study was to investigate the relationship between positive painful forced internal rotation (FIR) and lateral pulley instability in the presence of a pre-diagnosed posterosuperior cuff tear. The same investigation was conducted for painful active internal rotation (AIR). METHODS: a multicenter prospective study was conducted in a series of patients scheduled to undergo arthroscopic posterosuperior cuff repair. Pain was assessed using a visual analog scale (VAS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) was administered. The VAS score at rest, DASH score, and presence/absence of pain on FIR and AIR were recorded and their relationships with lesions of the lateral pulley, cuff tear patterns and shape of lesions were analyzed. RESULTS: the study population consisted of 115 patients (mean age: 55.1 years) recruited from 12 centers. The dominant arm was affected in 72 cases (62.6%). The average anteroposterior extension of the lesion was 1.61 cm. The mean preoperative VAS and DASH scores were 6.1 and 41.8, respectively. FIR and AIR were positive in 94 (81.7%) and 85 (73.9%) cases, respectively. The lateral pulley was compromised in 50 cases (43.4%). Cuff tears were partial articular in 35 patients (30.4%), complete in 61 (53%), and partial bursal in 19 (16.5%). No statistical correlation between positive FIR or AIR and lateral pulley lesions was detected. Positive FIR and AIR were statistically associated with complete lesions. Negative FIR was associated with the presence of partial articular tears. CONCLUSIONS: painful FIR in the presence of a postero-superior cuff tear does not indicate lateral pulley instability. When a cuff tear is suspected, positive FIR and AIR are suggestive of full-thickness tear patterns while a negative FIR suggests a partial articular lesion. LEVEL OF EVIDENCE: level I, validating cohort study with good reference standards.

Stemless shoulder arthroplasty: a literature review.

The design of humeral implants for shoulder arthroplasty has evolved over the years. The new-generation modular shoulder prostheses have an anatomical humeral stem that replicates the three-dimensional parameters of the proximal humerus. An anatomical reconstruction is the best way to restore stability and mobility of the prosthetic shoulder and improve implant durability. However, a perfect anatomical match is not always possible in, for example, patients with post-traumatic osteoarthritis of the shoulder and deformities in the metaphyseal region. To avoid stem-related complications while retaining the advantages of the fourth generation of shoulder implants, different stemless implants have been developed. The stemless shoulder prosthesis is a new concept in shoulder arthroplasty. The authors review the indications, surgical technique, clinical and radiological midterm results, and complications of these humeral implants.

Reproducible noninvasive method for evaluation of glenoid bone loss by multiplanar reconstruction curved computed tomographic imaging using a cadaveric model.

PURPOSE: To determine if the measurement of the glenoid surface by computed tomography (CT) with curved multiplanar reconstructions (cMPR) in a cadaveric model is an accurate and reproducible technique. METHODS: Ten dried cadaveric glenoid specimens were used. Two glenoids were subsequently modified mechanically to induce a bony Bankart lesion. Three skilled musculoskeletal radiologists performed cMPR on computed tomographic images of the glenoids; one of the radiologists repeated the same measurements after 3 months. Two of the 3 operators used the traditional "flat" MPR method as a control. An optical scanning system using a high-precision laser (CAM2 Laser Line Probe, Faro Technologies, Lake Mary, FL) was used as a reference. From the data obtained, an evaluation was performed for variability, degree of interoperator and intraoperator agreement, and degree of agreement between the laser and CT methods. Statistical analysis was performed with PASW-SPSS, version 18 (IBM, Armonk, NY) and R, version 2.12 statistical package. RESULTS: The average difference between the 2 sets of cMPR measurements was approximately 1%, and maximum and minimum values were between 6.02% and -0.29%. The flat MPR method showed mean differences of 16% when compared with laser scanning, and maximum and minimum values were 31% and 8%, respectively. The interoperator variability for the "curved" method was limited and showed a coefficient of variation ranging from 0.78% to 2.82%. The Cronbach alpha coefficient for this set of measurements was alpha = 0.995. There was little intraoperator variability with the coefficient of variation between 0% and 2% and an intraclass correlation coefficient of 0.989. CONCLUSIONS: The use of cMPR computed tomographic imaging of the glenoid in a cadaveric model was found to be significantly more accurate than conventional MPR (flat MPR). Moreover, cMPR CT is a reproducible technique providing reliable information despite the relevant variable anatomy of the glenoid surface. This technique could reasonably also be used in a clinical setting as a more accurate noninvasive method. CLINICAL OF RELEVANCE: This technique could also reasonably be used in a clinical setting as a more accurate noninvasive method.

Recurrent anterior shoulder dislocation with glenoid bone loss and concurrent irreparable rotator cuff tear in a young patient: case report.

Full-thickness rotator cuff tear associated with gleno-humeral anterior dislocation is a rare injury in patients younger than 40 years of age. We here report a case of recurrent anterior shoulder dislocation with glenoid bone loss and concurrent irreparable rotator cuff tear in a young patient. This is, to the best of our knowledge, the first such case reported in the literature. We also discuss the type of surgical treatment adopted and the measures that can be undertaken to address both instability and massive rotator cuff tear.

Arthroscopically assisted latissimus dorsi transfer with a minimally invasive harvesting technique: surgical technique and anatomic study.

Latissimus dorsi musculotendinous transfer has been described for the treatment of massive rotator cuff defects. The aim of this paper is to present the relevant surgical anatomy of an arthroscopically assisted technique associated with a modified harvesting of the tendon. For tendon harvesting, a skin incision of about 5-6 cm in length is made in the axillary crease orthogonal to the longitudinal axis of the upper arm. For the musculotendinous transfer, we propose to increase vector action of the latissimus dorsi by passing the transferred tendon ahead the triceps muscle under or over the Teres Major and fixing the transferred tendon behind the humeral head center of rotation in a more posterolateral position. In order to check the feasibility and safety of this new surgical technique, two fresh-frozen adult cadaveric hemithorax specimens with an intact upper extremity were dissected, and the relationships between the tendons and local neurologic structures were described during various steps of the latissimus dorsi transfer procedure.

Recurrent superior labral anterior-to-posterior tears after surgery: detection and grading with CT arthrography.

PURPOSE: To retrospectively evaluate the sensitivity and specificity of multidetector computed tomographic (CT) arthrography for the detection of recurrent superior labral anterior-to-posterior (SLAP) tears in the shoulder of patients who have previously undergone shoulder surgery and are clinically suspected of having a recurrent tear. MATERIALS AND METHODS: The hospital ethics board did not require patient approval or informed consent for this retrospective review of case records. Multidetector CT arthrograms of 45 shoulders of 45 patients (35 men, 10 women; mean age, 29 years; age range, 21-38 years) who had undergone conventional arthroscopy within 30 days after the CT arthrographic examination were reviewed. Owing to the referral patterns at the authors' institution, all patients were professional athletes. Volumetric multidetector CT arthrography was performed by using a 16-detector CT scanner after the intraarticular injection of iodinated contrast material. All images were independently reviewed by two experienced musculoskeletal radiologists, with disagreements resolved by a third experienced musculoskeletal radiologist. The sensitivity and specificity of multidetector CT arthrography in the detection of any Snyder type II-IV tear was evaluated by using arthroscopy as the reference standard. The numbers and percentages of tears that were assigned the correct Snyder classification with multidetector CT arthrography were reported. Interobserver agreement regarding the correct Snyder classification with multidetector CT arthrography was determined by using kappa statistics. RESULTS: With multidetector CT arthrography, recurrent SLAP tears were correctly identified in 35 of 37 patients (95% sensitivity), and the absence of these tears was correctly noted in seven of eight patients (88% specificity). Multidetector CT arthrography- and arthroscopy-derived tear grades were in agreement in 30 (81%) of 37 patients with recurrent SLAP tears. Interobserver agreement at multidetector CT arthrography was substantial (kappa = 0.76). CONCLUSION: In the described highly selected patient population, multidetector CT arthrography was useful for evaluating recurrent SLAP tears.