Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: does it work?

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis. At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively. Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of pectoralis major, particularly if there is pre-operative anterior subluxation of the humeral head.

[Arthroscopic reconstruction of the rotator cuff. The current gold standard?]. / Die arthroskopische Rekonstruktion der Rotatorenmanschette. Der gegenwärtige Goldstandard?

Arthroscopic rotator cuff repair has become the gold standard, and is now accepted throughout the world as the method of choice, for rotator cuff repair. As well as an experienced surgeon and meticulously correct arthroscopic technique, careful patient selection and adequate postoperative management are of decisive importance if a good postoperative outcome is to be achieved. With due consideration for all these factors the success rate is over 90%, as measured not only with reference to objective criteria, but also by patients' reports of their how satisfied they are with the result. This paper aims to report the indications, arthroscopic technique and postoperative protocol, and also the results of arthroscopic rotator cuff repair.

Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears.

On the basis of a modified Constant scoring system, we compared outcomes for 16 patients who underwent latissimus dorsi transfer as a salvage reconstruction for a failed prior rotator cuff repair with outcomes for 6 patients who underwent a primary reconstruction for an irreparable cuff defect. There was a statistically significant difference in Constant score between groups, which measured 55% for the salvage group compared with 70% for the primary group (P <.05). Poor tendon quality, stage 4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score (P <.05). Late rupture of the tendon transfer occurred in 44% of patients in the salvage group compared with 17% in the primary group at a mean of 19 months postoperatively. Rupture had a statistically significant effect on the Constant score, which declined by a mean of 14% (P <.05). We conclude that salvage reconstruction of failed prior rotator cuff repairs yields more limited gains in satisfaction and function than primary latissimus dorsi transfer.

Comparison of results of percutaneous balloon mitral commissurotomy in patients aged > or = 65 years with those in patients aged < 65 years.

Percutaneous balloon mitral commissurotomy (PBMC) is now first-line therapy in patients with symptomatic mitral stenosis (MS) and favorable valve morphology. Unfortunately, the outcome of Medicare-aged patients undergoing this procedure has not previously been defined. The results of PBMC in 55 patients > or = 65 years old (71 +/- 6 years) with moderate or severe MS were compared with 268 younger patients (47 +/- 10). Preprocedural New York Heart Association functional class and pulmonary pressures did not differ. The older patients had higher blood pressure, were more likely to be in atrial fibrillation and had higher valve scores (9.9 +/- 2.5 vs 8.6 +/- 2.2, p = 0.001). Procedural success was higher in the younger group (71% vs 55%, p = 0.013), with a greater increase in mitral valve area. Complications were similar in both groups and there were no periprocedural deaths. At 6 months a significant improvement in function class was seen in both groups. Restenosis, as assessed by serial echocardiography, occurred at a rate of 0.06 cm(2)/year in both groups, and functional class remained unchanged over 3 years. Event-free survival was similar at 48 months: 76% in the younger group and 69% in the older group. Our data thus demonstrates that PBMC can be safely performed in the Medicare-aged population. Despite less acute success in the older population, complication rates do not differ and decrement in valve area over time occurs at a similar rate. Functional class remains improved and event-free survival over 4 years appears similar in both groups. PBMC should thus be offered to patients with MS and suitable anatomy regardless of their age.

Instability of shoulder arthroplasty: balancing mobility and stability.

Avoidance of instability after shoulder arthroplasty is based on an appreciation of normal articular anatomy and its restoration, as well as adequate soft tissue release and secure repair of subscapularis. Errors in restoration of articular anatomy, or disruption of soft tissues about the joint, are the principal reasons for instability. Revision in such cases can be challenging because of difficulties in restoring normal articular position and orientation, as well as reconstruction of deficient soft tissues.

Shoulder proprioception in baseball pitchers.

We examined proprioceptive differences between the dominant and nondominant shoulders of 21 collegiate baseball pitchers without a history of shoulder instability or surgery. A proprioceptive testing device was used to measure kinesthesia and joint position sense. Joint position sense was significantly (P =.05) more accurate in the nondominant shoulder than in the dominant shoulder when starting at 75% of maximal external rotation and moving into internal rotation. There were no significant differences for proprioception in the other measured positions or with kinesthesia testing. Six pitchers with recent shoulder pain had a significant (P =.04) kinesthetic deficit in the symptomatic dominant shoulder compared with the asymptomatic shoulder, as measured in neutral rotation moving into internal rotation. The net effect of training, exercise-induced laxity, and increased external rotation in baseball pitchers does not affect proprioception, although shoulder pain, possibly due to rotator cuff inflammation or tendinitis, is associated with reduced kinesthetic sensation.

Arthroscopic shoulder reconstruction: fast-track recovery and outpatient treatment.

Arthroscopic shoulder reconstructive surgery has been handled in many different ways. However, there currently is significant evidence and experience to show that doing this surgery on an outpatient basis is not only cost-effective and efficient, but safe and beneficial to patients. New arthroscopic surgical techniques and the use of regional interscalene anesthesia have been shown to provide effective and comfortable intraoperative conditions, while allowing for prolonged analgesia and quicker recovery with minimal side effects. The authors will discuss their approach to surgery, anesthesia, and recovery for outpatient shoulder reconstruction.

Superior labral lesions: anatomy, pathology, and treatment.

In 1985, Andrews et al first described superior labral lesions primarily located in the anterosuperior aspect of the labrum in 73 athletes who throw overhead. Subsequently, Snyder et al coined the term superior labrum anterior to posterior lesion by identifying and classifying injury to the labrum that originated posteriorly and extended anteriorly. During the past 15 years, these superior labral injuries have been the source of approximately 70 peer-reviewed publications in the English language literature. Substantial debate continues, however, with reference to the pathogenesis, diagnosis, and treatment of these lesions. The current review defines the anatomy, possible etiologies, diagnosis, and treatment of injuries to the superior labrum.

Management of massive irreparable rotator cuff tears: the role of tendon transfer.

The inability to repair a rotator cuff tear is not uncommon, and in practices devoted to the management of shoulder injuries up to 30% of rotator cuff tears may be irreparable. The anterior and posterior components of the rotator cuff are the most important deficient areas. In the case of an irreparable subscapularis tendon tear, pain relief and stability appear to be reliably achieved by a split pectoralis major transfer; however, functional improvement is less certain because the biomechanics associated with this tendon transfer do not appear to be optimal. In the case of an irreparable posterosuperior rotator cuff tear, a latissimus dorsi tendon transfer reliably restores flexion and relieves pain; however, its use after failure of prior rotator cuff surgery makes the outcome less predictable. Both anterior and posterior reconstructions with tendon transfer require precise surgical technique and patient compliance with postoperative rehabilitation.

Diagnosis and treatment of anterosuperior rotator cuff tears.

Nineteen of 407 patients who underwent rotator cuff repair surgery over a 6-year period were found to have a tear of the subscapularis in combination with the supraspinatus and infraspinatus tendons. Nine of these patients had an unsuccessful prior surgery, which failed to recognize the extent of the subscapularis component. Surgical repair of the subscapularis tendon required a deltopectoral approach, and repair of the supraspinatus and infraspinatus components of the tear could only be accomplished through this approach in 4 patients. In the remaining 15, an extended superior approach was required to mobilize and repair the supraspinatus and infraspinatus tendons. In all cases, the biceps tendon was either torn or severely degenerated, requiring tenodesis. At a mean follow-up of 40 months (range 24 to 75 months), subjective results were excellent in 5 patients, good in 3, fair in 4, and poor in 7. The modified Constant score improved to a mean of 69% (range 23% to 130%), compared with a preoperative mean of 38% (range 23% to 100%). Physical findings positive for subscapularis insufficiency persisted in 14 of 19 patients. A significant correlation (P <.05) was found between a lower Constant score and duration of symptoms longer than 6 months as well as an appearance of severe fatty degeneration and atrophy of the subscapularis muscle on magnetic resonance imaging. We conclude that anterosuperior rotator cuff tears are an infrequent configuration that may require surgical repair through an extended approach combining deltopectoral mobilization of the subscapularis with transdeltoid mobilization of the supraspinatus and infraspinatus. Repair before 6 months of symptoms is associated with a better functional outcome and is the result of less involution of muscle and tendon tissue.

Arthroscopic Bankart repair with the Suretac device for traumatic anterior shoulder instability in athletes.

Arthroscopic treatment of anterior shoulder instability in the athlete has evolved tremendously over the past decade. Currently, most techniques include the use of suture and suture anchors. However, the variety of arthroscopic instruments and techniques that are available shows the complexity of intra-articular tissue fixation, which includes anchor placement, suture passing, and knot tying. Stabilization using the Suretac device (Acufex Microsurgical, Mansfield, MA) simplifies tissue fixation by eliminating the need for arthroscopic suture passing and intra-articular knot tying. However, a successful outcome is highly dependent on accurate patient selection. Preoperative evaluation, examination under anesthesia, and the pathoanatomy defined by a thorough arthroscopic examination suggest the most effective treatment strategy. The ideal candidate for shoulder stabilization using the Suretac device is an athlete with a relatively pure traumatic anterior instability pattern with detachment pathology (e.g., Bankart lesion) and minimal capsular deformation.

Inhaled nitric oxide selectively dilates pulmonary vasculature in adult patients with pulmonary hypertension, irrespective of etiology.

OBJECTIVES: We sought to compare the responses of patients with pulmonary hypertension from primary and secondary causes (PPH and SPH, respectively) to inhaled nitric oxide (iNO) in the cardiac catheterization laboratory. BACKGROUND: Pulmonary hypertension can lead to right ventricular pressure overload and failure. Although vasodilators are effective as therapy in patients with PPH, less is known about their role in adults with SPH. Inhaled nitric oxide can accurately predict the response to other vasodilators in PPH and could be similarly utilized in SPH. METHODS: Forty-two patients (26 to 77 years old) with pulmonary hypertension during cardiac catheterization received iNO. Demographic and hemodynamic data were collected. Their response to iNO was defined by a decrease of > or =20% in mean pulmonary artery (PA) pressure or pulmonary vascular resistance (PVR). RESULTS: Mean PA pressures and PVR were lower during nitric oxide (NO) inhalation in all patients with pulmonary hypertension. Seventy-eight percent of patients with PPH and 83% of patients with SPH were responders to iNO. A trend was seen toward a greater response with larger doses of NO in patients with SPH. Nitric oxide was a more sensitive predictor of response (79%), compared with inhaled oxygen (64%), and was well tolerated, with no evidence of systemic effects. Elevation in right ventricular end-diastolic pressure appeared to predict poor vasodilatory response to iNO. CONCLUSIONS: Nitric oxide is a safe and effective screening agent for pulmonary vasoreactivity. Regardless of etiology of pulmonary hypertension, pulmonary vasoreactivity is frequently demonstrated with the use of NO. Right ventricular diastolic dysfunction may predict a poor vasodilator response.

Experimental investigation of reaction forces at the glenohumeral joint during active abduction.

Reaction forces at the glenohumeral joint counterbalance the mass moment of the upper extremity during shoulder motion and are directly related to the activity of muscles across the joint. Because stability of the glenohumeral joint depends on compression of the humeral head into the glenoid, reaction forces constitute an important aspect of shoulder biomechanics. The objective of this study was to measure reaction forces at the glenohumeral joint during active scapula plane abduction. Furthermore, to clarify the relationship between the deltoid and supraspinatus muscles throughout abduction, this study investigated the effect of 4 variations of applied muscle forces on the magnitude and direction of glenohumeral reaction forces. We used a dynamic shoulder testing apparatus equipped with a force-moment sensor to directly measure reaction forces. Joint reaction forces increased throughout abduction and peaked at approximately 90 degrees for all testing conditions. The largest reaction forces occurred when the ratio of applied forces favored the supraspinatus tendon, whereas simulated paralysis of the supraspinatus resulted in a significant decrease in joint compression. There were no differences in direction of the reaction force between testing conditions. The results of this study indicate that the magnitude of glenohumeral joint reaction forces varies according to the ratio of forces between the supraspinatus and deltoid muscles. Thus, conditions characterized by either deltoid or supraspinatus dysfunction may result in abnormal loading mechanics at the glenohumeral joint. Understanding the relationship between rotator cuff function and glenohumeral reaction forces will aid in clarifying the importance of muscular activity to shoulder stability and strength as it relates to compression of the humeral head.

Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-up study.

BACKGROUND: Sixty-three consecutive patients with recurrent traumatic anterior shoulder instability underwent operative repair. The decision to select either arthroscopic Bankart repair or open capsular shift was based on the findings of an examination under anesthesia and the findings at the time of arthroscopy. Thirty-nine patients with only anterior translation on examination under anesthesia and a discrete Bankart lesion underwent arthroscopic Bankart repair with use of absorbable transfixing implants. Twenty-four patients with inferior translation in addition to anterior translation on examination under anesthesia and capsular laxity or injury on arthroscopy underwent an open capsular shift. METHODS: Treatment outcomes for each group were determined according to the scoring systems of Rowe et al., the American Shoulder and Elbow Surgeons, and the Short Form-36. Failure was defined as recurrence of dislocation or subluxation or the finding of apprehension. Fifty-nine (94 percent) of the sixty-three patients were examined and filled out a questionnaire at a mean of fifty-four months (range, twenty-seven to seventy-two months) following surgery. RESULTS: There were no significant differences between the two groups with regard to the prevalence of failure or any of the other measured parameters of outcome. An unsatisfactory outcome occurred after nine (24 percent) of thirty-seven arthroscopic repairs and after four (18 percent) of twenty-two open reconstructions. All cases of recurrent instability resulted from a reinjury in a contact sport or a fall less than two years postoperatively. The treatment groups did not differ with regard to patient age, hand dominance, mechanism of initial injury, duration of follow-up, or delay until surgery. Measured losses of motion were minimal and, with the exception of forward elevation, slightly more of which was lost after the open capsular shifts (p = 0.05), did not differ between the two forms of treatment. Approximately 75 percent of the patients in each group returned to their favorite recreational sports with no or mild limitations. As rated by the patients, the result was good or excellent after thirty-one (84 percent) of the arthroscopic procedures and after twenty (91 percent) of the open procedures. CONCLUSIONS: Arthroscopic and open repair techniques for the treatment of recurrent traumatic shoulder instability yield comparable results if the procedure is selected on the basis of the pathological findings at the time of surgery.

Outcomes following interventions in small coronary arteries with the use of hand-crimped Palmaz-Schatz stents.

Although coronary stenting has been shown to be effective, retrospective studies have suggested that stents do not provide better results than angioplasty in small coronary arteries. We sought to examine procedural, in-hospital, and long-term outcomes of patients undergoing small-vessel stenting with Palmaz-Schatz stents hand-crimped on a balloon catheter <3 mm in diameter. We retrospectively analyzed the outcomes of 117 patients who underwent this type of coronary stent implantation at Duke University Medical Center between January 1, 1997 and May 30, 1998. The clinical indications for percutaneous revascularization included unstable angina in 67.5% of patients, acute myocardial infarction in 4.3%, postinfarct angina in 3.4%, silent ischemia in 3.4%, and stable angina in 1% of patients. Quantitative angiographic analysis was performed immediately before angioplasty and after stent implantation. Stents were used for elective indications in 24%, for suboptimal angiographic result in 61.5%, and for abrupt and/or threatened closure in 14.5% of patients. Reference vessel diameter was similar before and after the procedure. Minimum luminal diameter increased from 0.63 to 2.35 mm, an acute gain of 1.72+/-0.43 mm. Percent stenosis decreased from 74.2% to 4.7%. The clinical composite of death (n = 1, 1%), nonfatal myocardial infarction (n = 6, 5.1%), and revascularization (n = 1, 1%) occurred in-hospital in only 8 patients (6.8%), resulting in clinical procedure success in 109 patients (93%). Our data suggest that stents designed for vessels >3.0 mm can be deployed in small vessels, with a low in-hospital event rate. However, target lesion revascularization in small vessels remains high. Development of antiproliferative strategies could improve long-term outcomes for small-vessel interventions.

Percutaneous stenting of right pulmonary artery stenosis in fibrosing mediastinitis.

Pulmonary artery stenosis is an uncommon complication of fibrosing mediastinitis. Previous medical and surgical therapies have provided limited clinical efficacy without objective evidence of clinical improvement. With the advantages of limited invasiveness and absent need for prolonged drug therapy, percutaneous stent deployment to relieve pulmonary artery obstruction represents a novel treatment for this rare disorder.

Selective capsular shift technique for anterior and anterior-inferior glenohumeral instability.

Anterior and anterior-inferior glenohumeral instability is often successfully treated with nonoperative measures, especially in atraumatic instability. In the case of traumatic instability, especially when the labrum is detached from the anteroinferior glenoid rim, surgery is often necessary to stabilize the shoulder and restore function. An anatomic repair that addresses any capsular or labral defect is essential for a successful outcome, and the selective capsular shift technique offers the flexibility necessary to correct these deformities. Several equally important steps must be followed when treating anterior and anterior-inferior glenohumeral instability. These include the correct diagnosis and indications for surgery; a technically successful surgical procedure; and diligent, physician-directed, closely monitored rehabilitation.