Cemented or cementless humeral fixation in reverse total shoulder arthroplasty? a systematic review.

AIMS: To date, there is insufficient evidence available to compare the outcome of cemented and uncemented fixation of the humeral stem in reverse shoulder arthroplasty (RSA). METHODS: A systemic review comprising 41 clinical studies was performed to compare the functional outcome and rate of complications of cemented and uncemented stems in RSA. These included 1455 cemented and 329 uncemented shoulders. The clinical characteristics of the two groups were similar. Variables were compared using pooled frequency-weighted means and relative risk ratios (RR). RESULTS: Uncemented stems had a significantly higher incidence of early humeral stem migration (p < 0.001, RR 18.1, 95% confidence interval (CI) 5.0 to 65.2) and non-progressive radiolucent lines (p < 0.001, RR 2.4, 95% CI 1.7 to 3.4), but a significantly lower incidence of post-operative fractures of the acromion compared with cemented stems (p = 0.004, RR 14.3, 95% CI 0.9 to 232.8). There was no difference in the risk of stem loosening or revision between the groups. The cemented stems had a greater relative risk of infection (RR 3.3, 95% CI 0.8 to 13.7), nerve injury (RR 5.7, 95% CI 0.7 to 41.5) and thromboembolism (RR 3.9, 95% CI 0.2 to 66.6). The functional outcome and range of movement were equivalent in the two groups. DISCUSSION: RSA performed with an uncemented stem gives them equivalent functional outcome and a better complication profile than with a cemented stem. The natural history and clinical relevance of early stem migration and radiolucent lines found with uncemented stems requires further long-term study. TAKE HOME MESSAGE: This study demonstrates that uncemented stems have at least equivalent clinical and radiographic outcomes compared with cemented stems when used for reverse total shoulder arthroplasty.

The functional range of motion of the finger joints.

The purpose of this study was to measure the functional range of motion of the finger joints needed to perform activities of daily living. Using the Sollerman hand grip function test, 20 activities were assessed in ten volunteers. The active and passive range of motion was measured with a computerized electric goniometer. The position of each finger joint was evaluated in the pre-grasp and grasp positions. The functional range of motion was defined as the range required to perform 90% of the activities, utilizing the pre-grasp and grasp measurements. The functional range of motion was 19°-71°, 23°-87°, and 10°-64° at the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, respectively. This represents 48%, 59%, and 60% of the active motion of these joints, respectively. There was a significant difference in the functional range of motion between the joints of the fingers, with the ulnar digits having greater active and functional range. The functional range of motion is important for directing indications for surgery and rehabilitation, and assessing outcome of treatment.

An association between lunate morphology and scaphoid-trapezium-trapezoid arthritis.

The purpose of this study was to determine if an association exists between scaphoid-trapezium-trapezoid arthritis and lunate morphology. Plain neutral posteroanterior radiographs were evaluated for 48 patients with STT arthritis and 96 patients from a control group. Lunate type was determined using capitate-triquetrum (C-T) distance. A type I lunate was defined as a C-T distance < or =2 mm. A type II lunate was defined as a C-T distance > or =4 mm. Lunate type was recorded and compared between those with STT arthritis and a control group. The groups were similar with regard to age, gender and handedness. Type II lunates were found in 83% of cases with STT arthritis and in 64% of controls. STT OA was associated with type II lunate wrists (P = 0.02; OR = 0.35; CI: 0.15-0.82). We postulate that variations in scaphoid motion secondary to lunate morphology may contribute to the development of STT OA.

Effect of scaphoid and triquetrum excision after limited stabilisation on cadaver wrist movement.

This study assessed the effect of excision of the scaphoid and triquetrum on the range of motion of the embalmed cadaver wrist joint after midcarpal stabilisation. The range of motion was measured in 12 cadaver wrists before and after stabilisation of the joints between the lunate, capitate, triquetrum and hamate. This was measured again following resection of the scaphoid and then the triquetrum. Scaphoid excision after four-corner stabilisation increased the radioulnar (RU) arc by 12 degrees and the flexion-extension (F-E) arc by 10 degrees. Subsequent excision of the triquetrum, to produce a three-corner stabilisation, further increased the RU arc by 7 degrees and the F-E arc by 6 degrees. Three-corner stabilisation with excision of scaphoid and triquetrum improved wrist motion in embalmed cadavers.

A history of carpal tunnel syndrome.

Carpal tunnel syndrome is the commonest entrapment neuropathy seen in clinical practice. The history of its aetiology and diagnosis gives an interesting insight into how the condition has evolved to also become the best understood neuropathy.

Clinical Results of Coracoacromial Ligament Transfer in Acromioclavicular Dislocations: a Review of Published Literature

Acromioclavicular joint dislocations are common injuries; which typically occur with trauma in young men. Treatment recommendations for these injuries are highly variable and controversial. There are greater than 100 surgical techniques described for operative treatment of this injury. One of the most widely recommended methods of surgical recons- truction for acromioclavicular joint dislocations is to utilize the coracoacromial ligament for stabilization of the distal clavicle. Several modifications of this procedure have been described which have involved adjunct coracoclavicular fixation or fixation across acromioclavicular joint. Although the literature is replete with descriptive papers; there is paucity of studies evaluating the surgical outcome of this procedure. We systematically reviewed the eng language published literature in peer reviewed journals (Medline; EMBASE; SCOPUS) and assigned a level of evidence for available studies. We critically reviewed each paper for the flaws and biases and then evaluated the comparable clinical outcomes for various procedures and their modifications. The published literature consists entirely of case series (Level IV evidence) with variability in surgical technique and outcome measures. On review there is low level evidence to support the use of coracoacromial ligament for acromioclavicular dislocation but it has been associated with high rate of deformity recurrence. Adjunct fixation does not improve clinical results when compared to isolated coracoacromial ligament transfer. This is in part because of the high incidence of fixation related complications. Similar results are reported with coracoacromial ligament reconstruction for acute and chronic cases. The development of secon- dary acromioclavicular joint symptoms with distal clavicle retention is poorly reported with the incidence rate varying from 12to 32. Despite this; the retention or excision of distal clavicle did not affect overall clinical results except in the patients with pre existing acromioclavicular joint osteoarthritis who have inferior results with retention of distal end of clavicle. Further well designed clinical trials with validated outcome measures are required to fully evaluate the clinical results of this procedure

Distal biceps tendon anatomy: a cadaveric study.

BACKGROUND: The anatomy of the distal biceps tendon and aponeurosis has not been studied in detail. METHODS: Seventeen cadaver elbows were dissected with loupe magnification to identify the details of the distal biceps tendon and the lacertus fibrosus. RESULTS: In ten of the seventeen specimens, the distal biceps tendon was in two distinct parts, each a continuation of the long and short heads of the muscle. The remaining seven specimens showed interdigitation of the muscle distally. The tendon continued from each muscle belly. The short head inserted distal to the radial tuberosity and was positioned to be a more powerful flexor of the elbow, while the tendon of the long head inserted on the tuberosity further from the axis of rotation of the forearm and was positioned to be a stronger supinator. The bicipital aponeurosis consisted of three layers and completely encircled the ulnar forearm flexor muscles. The aponeurosis may be important in stabilizing the tendons distally. CONCLUSIONS: The double tendon insertion may allow an element of independent function of each portion of the biceps, and, during repair of an avulsion, the surgeon should ensure correct orientation of both tendon components.

Management of Mason type-III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. Surgical technique.

BACKGROUND: Radial head fractures often occur in association with other elbow fractures and soft-tissue injuries. Radial head replacement is indicated for irreparable radial head fractures associated with elbow instability. The purpose of this study was to analyze the results after treatment of such injuries with a titanium radial head prosthesis, repair of torn collateral ligaments, and early mobilization of the elbow. MATERIALS: Sixteen patients with sixteen Mason type-III radial head fractures and collateral ligament injury were treated with use of a titanium radial head prosthesis over a five-year period at the Royal Adelaide Hospital and Modbury Public Hospital in South Australia. The surgery was performed acutely in ten patients and was delayed an average of thirty-seven days (range, fifteen to seventy-nine days) in six. All patients were followed clinically and radiographically for a mean of 2.8 years (range, 1.2 to 4.3 years). RESULTS: Eight patients had an excellent result; five, a good result; and three, a fair result, according to the Mayo Elbow Performance Score. The three fair results occurred in patients with delayed surgery. The mean flexion contracture was 15 degrees (range, 0 degrees to 42 degrees ), with an average loss of 10 degrees (range, 0 degrees to 25 degrees ) of full flexion compared with that of the contralateral elbow. Both pronation and supination decreased an average of 12 degrees (range, 0 degrees to 45 degrees ) compared with that of the contralateral forearm. CONCLUSIONS: The results of treatment of Mason type-III radial head fractures with a monoblock titanium radial head prosthesis and soft-tissue reconstruction are satisfactory. Early mobilization of the elbow is important for the restoration of elbow range of motion and function.

Synthetic bone graft substitutes.

Replacement of extensive local bone loss is a significant clinical challenge. There are a variety of techniques available to the surgeon to manage this problem, each with their own advantages and disadvantages. It is well known that there is morbidity associated with harvesting of autogenous bone graft and limitations in the quantity of bone available. Alternatively allografts have been reported to have a significant incidence of postoperative infection and fracture as well as the potential risk of disease transmission. During the past 30 years a variety of synthetic bone graft substitutes has been developed with the aim to minimize these complications. The benefits of synthetic grafts include availability, sterility and reduced morbidity. The present article examines the relevance of synthetic bone graft substitutes, their mechanical properties and clinical application.

Sigmoid notch osteoplasty for chronic volar instability of the distal radioulnar joint: a case report.

Chronic recurrent volar dislocation of the distal radioulnar joint is a rare condition for which many operative procedures have been described. We describe a case of painful dislocation on supination. Investigation of the distal radioulnar joint revealed the absence of degenerative arthritis and a flat sigmoid notch that permitted dislocation. The case was successfully treated by osteoplasty of the volar lip of the sigmoid notch to create a buttress that prevented volar dislocation.

Osteoprotegerin and receptor activator of nuclear factor kappaB ligand (RANKL) regulate osteoclast formation by cells in the human rheumatoid arthritic joint.

OBJECTIVE: This study investigated the involvement of the recently identified regulators of osteoclast formation RANKL [receptor activator of nuclear factor kappaB (RANK) ligand, osteoclast differentiation factor, TRANCE, osteoprotegerin ligand] and its natural inhibitor, osteoprotegerin (OPG), in the bone erosion of rheumatoid arthritis (RA). METHODS: mRNA was extracted from cells isolated from the pannus and synovial membrane regions of joints of 11 RA patients. Semiquantitative reverse transcription-polymerase chain reaction was carried out, and the isolated cells were also cultured to determine their ability to form osteoclasts. RESULTS: mRNAs encoding RANKL, RANK, OPG and macrophage-colony stimulating factor were expressed by cells isolated from RA joints. In addition, mRNA encoding for tumour necrosis factor apoptosis-inducing ligand and the osteoclast markers tartrate-resistant acid phosphatase and calcitonin receptor were also often expressed. Osteoclasts capable of forming resorption lacunae were generated from cells in the RA joints. At 50 ng/ml, recombinant OPG completely inhibited the resorptive activity of these cells. There was a significant correlation between the ratio of RANKL mRNA to OPG mRNA and the number of resorption pits produced (P = 0.028). CONCLUSION: These data suggest that RANKL is an essential factor for osteoclast formation by cells in the rheumatic joint and that OPG may prevent the bone erosion seen in RA joints.

Digitally assisted acromioplasty: the effect of interscalene block on this new surgical technique.

PURPOSE: Interscalene brachial plexus (ISBP) block has been shown to be safe and effective for shoulder surgery with significant benefits. The purpose of this study was to introduce the technique of digitally assisted acromioplasty and assess the effect of ISBP on rehabilitation. TYPE OF STUDY: Randomized controlled prospective trial. METHODS: In a randomized prospective trial of 40 patients undergoing acromioplasty under general anesthesia, 20 patients received an ISBP block (group 1) and 20 had no block (group 2). A digitally assisted acromioplasty was performed using a burr introduced via a posterior portal. The undersurface of the acromion was debrided, directing the burr with the surgeon's index finger introduced via a small lateral incision. Independent review was at day 1, day 2, week 1, week 6, and 1 year. RESULTS: Group 1 had significantly greater shoulder motion and shoulder score, and less pain and analgesic requirements on the first day. These differences did not persist. Both groups had improved pain and function over time compared with preoperative scores. CONCLUSIONS: ISBP provides superior initial results but does not offer any significant persistent functional or rehabilitative advantage in the medium to long term. Digitally assisted acromioplasty is simple to perform and does not violate the deltoid insertion.

A systematic review of the content and quality of wrist outcome instruments.

OBJECTIVE: To assess the content and quality of published wrist outcome instruments using standardized criteria. DESIGN: An analytical study that examined 32 wrist outcome instruments sourced from textbooks, Medline (1951 to present) and Current Contents. MAIN MEASURES: The content of each instrument was classified into four categories: traditional measures (such as range of movement and strength), measures of the ability to perform daily activities, compensatory mechanisms used, and 'other'. Analysis included the frequency of assessment per category and the method of assessment. In addition, each instrument was graded using 13 quality criteria. Three criteria (scientific justification of the content and scoring system used, demographic utility) were considered to be essential. RESULTS: Eighty-two per cent of instruments reviewed for this paper contained traditional measures, of which most were assessed objectively. The ability to perform specific daily activities was assessed in 31% of the instruments whereas compensatory mechanisms were evaluated in only one instrument. These variables were not assessed in a consistent manner. Using the quality scoring system derived for this study, the quality of the instruments was generally poor. Only one instrument fulfilled all of the essential criteria. Only four instruments completely satisfied more than 50% of the criteria. CONCLUSIONS: Most wrist outcome instruments neglected to assess the impact of the disorder on the individual. Outcome was generally not expressed in functional terms or in terms that were relevant to each individual. The majority of the reviewed articles had poor quality. Thus use of these instruments may preclude sensitive evaluation of the efficacy of any intervention.

Repair of distal biceps tendon rupture: a new technique using the Endobutton.

The authors describe a technique with a single anterior incision and fixation with an internal button, the Endobutton. The procedure is performed through a 5-cm transverse skin incision, and the tendon is sutured to the Endobutton with 2 number 5 Ethibond sutures. Surgical repair in the depths of the muscular forearm is not required, because the tendon is simply sutured external to the wound. The Endobutton delivers and locks the tendon into a hole in the radial tuberosity. The Endobutton technique was used in 12 patients who were allowed early active mobilization. All were satisfied, returned to activities, and regained grade 5 strength. Average flexion was from 5 degrees to 146 degrees with 81 degrees supination and 80 degrees pronation. No neurovascular complications or synostosis occurred. In cadaveric studies the average distance from the biceps tendon were ulnar artery 6 mm, median nerve 12 mm, and posterior interosseous nerve 18 mm. The average distance from the posterior interosseous nerve to a Steinman pin advanced through the proximal radius was 14 mm. This technique is a safe and effective method of repair of distal biceps tendon avulsion that allows active mobilization with minimal risk of complication.

Anatomical reduction of intra-articular fractures of the distal radius. An arthroscopically-assisted approach.

We treated 31 intra-articular fractures of the distal radius by arthroscopically-assisted reduction and percutaneous fixation with Kirschner (K-) wires. Tears of the triangular fibrocartilage (58 %), scapholunate (85 %) and lunotriquetral (61%) instability and osteochondral lesions (19%) were also treated. A total of 26 patients was independently reviewed at an average of 19 months. The mean pain score was 1.3/10, the range of movement 79% and the grip strength 90% of the contralateral wrist. Using the New York Orthopaedic Hospital score, 88% were graded excellent to good. On follow-up radiographs, 65% had no step and 31% had a step of < or =1 mm. Pain was significantly related to the size of the step. There was a significant difference in the incidence of persistent scapholunate diastasis and the Leibovic and Geissler grade (p < 0.01): I (0%), II (0%), III (42%) and IV (100%). We recommend anatomical reduction and acceptance of a step of <1 mm since the size of the step is related to the incidence of pain.

Surgical approaches to the elbow.

The recent explosion of interest in the elbow and the need for better surgical approaches, has produced numerous new approaches and the modification of other approaches, the result of which is a much shorter but more useful list of surgical approaches. Surgeons who perform a large number of elbow procedures have found that these approaches permit them to perform the majority of elbow procedures with only one skin incision, usually a straight posterior midline incision. Knowledge of the deep intermuscular and internervous intervals allows the surgeon to expose the elbow circumferentially through one skin incision. This approach has been associated with fewer wound complications and has allowed immediate active motion of the elbow.

Arthroscopic capsular release for contracture of the wrist: a new technique.

SUMMARY: Stiffness of the wrist can occur following trauma or surgery. In some patients, loss of motion may be refractory to conservative treatment and operative treatment may thus be indicated. The authors report the results and technique of arthroscopic capsular release of the wrist. A cadaveric study was performed to assess the safety of arthroscopic capsular release. Arthroscopic capsular release was performed on 2 patients with limited wrist mobility. The average distance from the radiocarpal joint capsule to the neurovascular structures were 6.9 mm to the median nerve, 6.7 mm to the ulnar nerve and 5.2 mm to the radial artery. At 6 months follow-up, the average range of motion had improved from 17 degrees flexion and 10 degrees extension to 47 degrees flexion and 50 degrees extension. The average grip strength had improved from 13 to 31 kg. Pain measured on a visual analogue score (0-10) had improved from 1.5 to 1.0. There were no complications. Arthroscopic capsular release of the wrist is a safe and minimally invasive technique that provides good improvement to range of motion.

A review of complex trauma to the elbow.

This paper presents a review of common complex elbow traumatic disorders. It presents an algorithm to aid in the management of these cases and discusses indications for radial head replacement and dynamic external fixateurs.

Arthroscopic relationship of the axillary nerve to the shoulder joint capsule: an anatomic study.

Twelve right shoulders in fresh cadavers were dissected to determine the relation of the axillary nerve to the shoulder capsule and glenoid. Needles transfixed the nerve to the capsule and into the shoulder joint. Arthroscopy was performed to determine the location of the needles on the glenoid clock. The needles were then removed and the position of the shoulder changed to determine the effect on the position of the axillary nerve. The axillary nerve was held to the shoulder capsule with loose areolar tissue in the zone between 5 and 7 o'clock and was close to the glenoid in the neutral position, in extension, and in internal rotation. With shoulder abduction, external rotation, and perpendicular traction, the capsule became taut and the axillary nerve moved away from the glenoid. Abduction, external rotation, and perpendicular traction increase the zone of safety during arthroscopic anteroinferior capsulotomy adjacent to the glenoid between the 5 and 7 o'clock positions.

An overview of distal radial fractures.

Fractures of the distal radius include a wide spectrum of fracture patterns. As well as involving the distal radius, these injuries can involve the wrist, the distal radio-ulnar joint and the distal ulna. The management of these injuries is consequently diverse, ranging from a plaster cast to advanced surgery. The principles of treatment are to reduce and maintain the reduction by restoring the radial height, volar tilt and intra-articular step. The acceptable reduction is to have radial height to within 2 mm of the ulnar, volar tilt greater than 0 degree and intra-articular step less than 1 mm. The present paper reviews the current concepts in the diagnosis, management and complications of distal radial fractures.