Tendon transfers for irreparable rotator cuff tears: An update.

Shoulder dysfunction in the setting of irreparable rotator cuff tears (RCTs) can be treated successfully with different types of tendon transfer: Latissimus dorsi transfer for irreparable posterosuperior RCTs works best for young, active patients with an intact subscapularis, no pseudoparalysis or previous surgery, and a functioning teres minor.A more anatomical transfer for irreparable posterosuperior RCTs is a lower trapezius transfer, and early results are promising.Isolated irreparable tears of the subscapularis can be successfully managed with pectoralis major tendon transfer with a concentric humeral head. However, restricted external rotation (ER) may occur, depending on technique.Pectoralis minor transfer can successfully address combination irreparable tears of the upper border subscapularis and the supraspinatus without significant loss of ER.Rotator cuff arthropathy with ER lag benefits most from a reverse total shoulder arthroplasty and a combination latissimus dorsi and teres major transfer (LDTMT) regardless of patient age. Cite this article: Axe JM. Tendon transfers for irreparable rotator cuff tears: An update. EFORT Open Rev 2016;1:18-24. doi: 10.1302/2058-5241.1.000003.

NICKEL ALLERGY: Surgeons Beware.

When performing an orthopaedic device implantation, it should be routine practice for the surgeon to ask the patient if he or she has a metal allergy, and more specifically a nickel allergy. Ask the patient about costume jewelry or button reactions. If it is an elective surgery, obtain a confirmatory test with the aid of a dermatologist or allergist. It is recommended to use a non-nickel implant if the surgery is urgent, the patient has a confirmed allergy, or the patient does not want to undergo testing, as these implants are readily available in 2015. Finally, if the patient has a painful joint arthroplasty and all other causes have been ruled out, order a metal allergy test to aid in diagnosis.

High school wrestling tournament decision making.

OBJECTIVE: This study is designed to aid in safe coverage of a large scale wrestling tournament and to provide information transferable to other sporting tournaments. BACKGROUND: Catastrophic injuries dominate the concerns of the medical teams covering sporting events. Insights gained from years of experience by the same medical team for one of the premier high school wrestling tournaments offers practical knowledge for successful preparation of a large scale event. Necessary personnel, equipment, and supplies are critical. DIFFERENTIAL DIAGNOSIS: Skin conditions and injuries sustained while wrestling MEASUREMENTS: Event preparation was performed by the same medical staff for three years, 2006, 2008 and 2009. Skin checks were performed on over 750 wrestlers each year. Disqualifications for untreated or under treated conditions were made as necessary. Approximately 1,700 bouts a year were supervised by the medical personnel. All injuries sustained were recorded by the medical staff and necessary disqualifications were made. FINDINGS: Each year wrestlers presented with the appropriate skin forms. Only in 2009, did a wrestler not have adequate treatment for MRSA impetigo and was disqualified. There were no catastrophic injuries in the recorded years. Medical disqualifications were also infrequent. In 2006, 2008 and 2009, 6, 17, and 8 disqualifications occurred respectively. The most common type of injury each year was a sprain/strain. CONCLUSION: Many clinicians are fearful of leading the medical staff for tournaments of such size. The presented recommendations provide an understanding and categorical check list of necessary staffing, logistics, equipment, and supplies. Preparation for known sports specific anticipated injuries and return to play decision making should help, but only successful completion of the event will provide the necessary confidence.

Total hip arthroplasty as treatment for avascular necrosis secondary to slipped capital femoral epiphysis in a pre-teen.

BACKGROUND: While the treatment for avascular necrosis (AVN) secondary to slipped capital femoral epiphysis (SCFE) varies, it is rare that a pre-teenager will undergo a total hip arthroplasty (THA) in efforts to relieve pain and maintain function. METHODS: A-10-year old female sustained an unstable SCFE while playing on wet grass. Unfortunately, her femoral head demonstrated significant AVN after surgical hip dislocation. All treatment options were discussed with the patient and her family. The decision of the family was to have the patient undergo a THA. RESULTS: Approximately one year after her injury, a ceramic on ceramic THA was performed. Her post-operative Harris Hip Scores increased dramatically and she was able to walk without crutches for the first time since her injury. At one year post operatively, the patient was no longer taking narcotics, losing weight, and returned to her sporting activities. CONCLUSION: THA for SCFE in pre-teenagers is not a norm and should be considered on a case by case basis. This case report demonstrates a successful outcome and a review of options for the treatment of AVN secondary to SCFE.

The role of viscosupplementation.

The treatment of early osteoarthritis in middle-aged athletes with intra-articular (IA) viscosupplementation using hyaluronic acid (HA) has been used since the late 1980s. Administration of IA HA has demonstrated anti-inflammatory, anabolic, and analgesic effects. Treatment of acute injuries such as anterior cruciate ligament reconstruction and full thickness chondral lesions have benefited with the addition of IA HA. Use of IA HA has also been shown to delay total knee arthroplasty. Although IA HA has shown significant benefits in the middle-aged athletes, it is not a ubiquitous treatment option. Success with corticosteroid injections can be used as a clinical marker for subsequent success with HA injections.

97% accuracy of intra-articular glenohumeral injection with a modified (Delaware) posterior bone touch technique.

BACKGROUND: Unguided approaches have not demonstrated evidence of highly accurate intra-articular glenohumeral injections. The purpose of this study was to assess the accuracy of a posterior approach bone touch technique in conscious subjects without shoulder pathology as a first step in developing an accurate, reliable technique for use in patients. METHODS: Twenty-six young subjects (age 22-26) without shoulder pathology (BMI 24 +/- 3), had bilateral shoulders injected while awake and seated. A 20 gauge 3.5-inch needle was introduced 1.5 cm below the scapular spine mid-way between the posterior lateral acromial corner and the posterior axillary crease. In Trial I, 20 shoulders were injected. After touching the humerus, the arm was oscillated. The needle advanced to 4-5 cm and 10 mL of dye injected. Pop and ease of flow were recorded. Immediate room change, spot fluoroscopy, and independent experienced radiology reading followed. In Trial II, 32 shoulders were injected. The technique was modified to touching the humerus, externally rotating the arm 25 degrees, and while remaining in bone contact, delivering 10 mL of dye. The same data as Trial I was recorded. RESULTS: In Trial I, 14/20 (70 percent) had dye within the glenohumeral joint. Five of seven failures were too anterior showing dye around the subscapularis muscle and all were associated with a pop. In Trial II, 31/32 (97 percent) had dye within glenohumeral joint. Twenty-three of 32 (72 percent) had a "pop," including the failure. Overall, 45/52 (87 percent) had dye within glenohumeral joint. Thirty-one of 52 (71 percent) of all shoulders had a "pop." Twenty-three of 52 (44 percent) shoulders had pain, resolving within 24 hours. CONCLUSION: A modified (Delaware) posterior bone touch technique for glenohumeral joint injection is 97 percent accurate in conscious healthy young subjects. Pop and ease of flow are not always indicative of correct needle placement. This study serves as an important first step in determining an optimum approach for injecting pathologic glenohumeral joints with corticosteroids or hyaluronic acid. LEVEL OF EVIDENCE: IV Case Series.