Management of clavicle nonunion and malunion.

BACKGROUND: Clavicle fractures are common injuries of the shoulder girdle and occasionally result in nonunion or symptomatic malunion. When present, these chronic injuries can result in considerable shoulder dysfunction. A number of surgical techniques have been described for the management of these injuries. Current literature suggests that supplemental bone grafting may not be necessary in all cases but should be considered in the setting of atrophic nonunion. However, optimal treatment is controversial, as discussed in the literature. This article highlights the current treatment options based on the existing literature and describes our preferred techniques. METHODS: We carried out a comprehensive review of the PubMed and Medline databases using multiple keywords (eg, clavicle fracture, clavicle nonunion, and clavicle malunion) to identify the relevant literature regarding this topic. Reference lists of the relevant articles were reviewed for additional important articles. CONCLUSION: Nonunion and malunion of the clavicle remain challenging problems. Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique.

Biomechanical analysis of two-tendon posterosuperior rotator cuff tear repairs: extended linked repairs and augmented repairs.

PURPOSE: The purpose of this study was to compare single-row (SR), extended double-row (DR), and augmented, extended double-row (aDR) rotator cuff repairs in a two-tendon, posterosuperior rotator cuff tear (RCT) model with intact rotator cuff tendons. METHODS: RCTs were created and randomly assigned to SR, DR, or aDR repair (5 each) in 20 cadaveric shoulder specimens. A collagen scaffold was used for augmentation. In the remaining 5 specimens, the rotator cuffs were left intact. All specimens were cyclically loaded from 25 to 75 N for 50 cycles. Every 50 cycles, peak load was increased by 25 N until failure occurred. Cyclic stiffness and number of cycles were analyzed. RESULTS: The SR (72.9 ± 4.64 N/mm)- and aDR (72.6 ± 11.8 N/mm)-repaired specimens differed significantly in stiffness from the intact specimens (93.1 ± 14.8 N/mm) at ≥100 N (P < .05). The intact specimens and DR- and aDR-repaired specimens endured more cycles to failure (1,556 ± 677, 1,302 ± 248, and 1,211 ± 95, respectively) than the SR-repair specimens (388 ± 72 cycles, 260 ± 4 N) (P < .05 for all groups). CONCLUSIONS: Linked DR constructs were significantly stronger than SR repairs in this two-tendon RCT model and approached the strength of the intact rotator cuff. Augmentation with a collagen patch (aDR) did not influence biomechanical repair qualities in this model, but did result in less variability in failure load and more consistency in the mode of failure. CLINICAL RELEVANCE: The biomechanical properties of extended linked DR constructs are superior to those of SR constructs for repair of two-tendon RCTs, and are not compromised by graft augmentation.

An association between the inferior humeral head osteophyte and teres minor fatty infiltration: evidence for axillary nerve entrapment in glenohumeral osteoarthritis.

BACKGROUND: Glenohumeral osteoarthritis often results in inferior humeral osteophytes. Anatomic studies suggest that the axillary neurovascular bundle is in close proximity to the glenohumeral capsule. We therefore hypothesize that an inferior humeral osteophyte of sufficient magnitude could encroach on the axillary nerve and result in measurable fatty infiltration of the teres minor muscle. MATERIALS AND METHODS: Preoperative magnetic resonance imaging studies of 91 consecutive arthritic shoulders were retrospectively reviewed. Two cohorts were established based on the presence of a humeral osteophyte. The distances from the axillary neurovascular bundle to various osseous structures were measured using calibrated software. Objective quantitative measurements of the degree of fatty infiltration of the teres minor muscles were obtained with image analysis software. Results were compared between cohorts. RESULTS: The distance between the inferior humerus and axillary neurovascular bundle was inversely correlated to the size of the inferior humeral osteophyte (ρ = -0.631, P < .001). Fatty infiltration of the teres minor was greater when an inferior osteophyte was present (11.9%) than when an osteophyte was not present (4.4%) (P = .004). A statistically significant correlation between the size of the humeral head spur and quantity of fat in the teres minor muscle belly (ρ = 0.297, P = .005) was identified. CONCLUSION: These data are consistent with our hypothesis that the axillary nerve may be entrapped by the inferior humeral osteophyte often presenting with glenohumeral osteoarthritis. Entrapment may affect axillary nerve function and lead to changes in the teres minor muscle. Axillary neuropathy from an inferior humeral osteophyte may represent a contributing and treatable cause of pain in patients with glenohumeral osteoarthritis.

Reconstruction of posterior glenoid deficiency using distal tibial osteoarticular allograft.

Posterior shoulder instability with glenoid deficiency is a rare entity and its surgical treatment is challenging. Reconstructive techniques have focused on extra-articular structural bone transfer that obstructs humeral translation and thereby prevents glenohumeral dislocation. However, long-term results are not as promising. In this report, the authors describe a technique for anatomic posterior glenoid reconstruction using an osteoarticular distal tibia allograft in two patients including their outcomes after 2 years. Level of evidence IV.

Acromioclavicular joint separations.

Acromioclavicular (AC) joint separations are common injuries of the shoulder girdle, especially in the young and active population. Typically the mechanism of this injury is a direct force against the lateral aspect of the adducted shoulder, the magnitude of which affects injury severity. While low-grade injuries are frequently managed successfully using non-surgical measures, high-grade injuries frequently warrant surgical intervention to minimize pain and maximize shoulder function. Factors such as duration of injury and activity level should also be taken into account in an effort to individualize each patient's treatment. A number of surgical techniques have been introduced to manage symptomatic, high-grade injuries. The purpose of this article is to review the important anatomy, biomechanical background, and clinical management of this entity.

Technique and outcomes of arthroscopic scapulothoracic bursectomy and partial scapulectomy.

PURPOSE: The purpose of this study was to assess the efficacy of arthroscopic scapulothoracic bursectomy in patients with snapping scapula syndrome with a minimum of 2 years' follow-up. METHODS: In this institutional review board-approved retrospective study, 23 shoulders in 21 consecutive patients were identified that had undergone arthroscopic treatment of snapping scapula syndrome. Each patient described mechanical symptoms with failure of nonsurgical modalities and reported symptomatic relief from a local anesthetic injection before surgical intervention. Preoperative and postoperative pain and functioning levels were assessed with the American Shoulder and Elbow Surgeons (ASES), QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire), and Single Assessment Numeric Evaluation (SANE) shoulder scores, and patient satisfaction was recorded on a 10-point visual analog scale. Univariate and paired t tests were used for data analysis. Significance was established at P ≤ .05. RESULTS: The mean age at the time of surgery was 33 years (SD, 14 years). A scapulothoracic bursectomy alone was performed in 2 shoulders, and the remaining 21 shoulders underwent both bursectomy and scapuloplasty of the superomedial or inferomedial scapular border. At a mean follow-up of 2.5 years (SD, 0.57 years), a significant improvement in the median ASES score was noted, from 53 points (range, 17 to 83 points) preoperatively to 73 points (range, 32 to 100 points) postoperatively (P = .001). The mean SANE and QuickDASH scores at follow-up were 73 (SD, 27) and 35 (SD, 30), respectively. Overall, median patient satisfaction with surgical outcome was 6 of 10 (range, 1 to 10). Of the shoulders, 3 (13%) underwent revision for persistent scapulothoracic pain. CONCLUSIONS: Snapping scapula syndrome can be a debilitating disorder. Although significant pain and functional improvement can be expected after arthroscopic bursectomy and scapuloplasty, the average postoperative ASES and SANE scores remain lower than expected. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Rehabilitation after arthroscopic rotator cuff repair: current concepts review and evidence-based guidelines.

PURPOSE: To provide an overview of the characteristics and timing of rotator cuff healing and provide an update on treatments used in rehabilitation of rotator cuff repairs. The authors' protocol of choice, used within a large sports medicine rehabilitation center, is presented and the rationale behind its implementation is discussed. BACKGROUND: If initial nonsurgical treatment of a rotator cuff tear fails, surgical repair is often the next line of treatment. It is evident that a successful outcome after surgical rotator cuff repair is as much dependent on surgical technique as it is on rehabilitation. To this end, rehabilitation protocols have proven challenging to both the orthopaedic surgeon and the involved physical therapist. Instead of being based on scientific rationale, traditionally most rehabilitation protocols are solely based on clinical experience and expert opinion. METHODS: A review of currently available literature on rehabilitation after arthroscopic rotator cuff tear repair on PUBMED / MEDLINE and EMBASE databases was performed to illustrate the available evidence behind various postoperative treatment modalities. RESULTS: There is little high-level scientific evidence available to support or contest current postoperative rotator cuff rehabilitation protocols. Most existing protocols are based on clinical experience with modest incorporation of scientific data. CONCLUSION: Little scientific evidence is available to guide the timing of postsurgical rotator cuff rehabilitation. To this end, expert opinion and clinical experience remains a large facet of rehabilitation protocols. This review describes a rotator cuff rehabilitation protocol that incorporates currently available scientific literature guiding rehabilitation.

Glenohumeral joint preservation: a review of management options for young, active patients with osteoarthritis.

The management of osteoarthritis of the shoulder in young, active patients is a challenge, and the optimal treatment has yet to be completely established. Many of these patients wish to maintain a high level of activity, and arthroplasty may not be a practical treatment option. It is these patients who may be excellent candidates for joint-preservation procedures in an effort to avoid or delay joint replacement. Several palliative and restorative techniques are currently optional. Joint debridement has shown good results and a combination of arthroscopic debridement with a capsular release, humeral osteoplasty, and transcapsular axillary nerve decompression seems promising when humeral osteophytes are present. Currently, microfracture seems the most studied reparative treatment modality available. Other techniques, such as autologous chondrocyte implantation and osteochondral transfers, have reportedly shown potential but are currently mainly still investigational procedures. This paper gives an overview of the currently available joint preserving surgical techniques for glenohumeral osteoarthritis.

Treatment of clavicle fractures: current concepts review.

Clavicle fractures are common in adults and children. Most commonly, these fractures occur within the middle third of the clavicle and exhibit some degree of displacement. Whereas many midshaft clavicle fractures can be treated nonsurgically, recent evidence suggests that more severe fracture types exhibit higher rates of symptomatic nonunion or malunion. Although the indications for surgical fixation of midshaft clavicle fractures remain controversial, they appear to be broadening. Most fractures of the medial or lateral end of the clavicle can be treated nonsurgically if fracture fragments remain stable. Surgical intervention may be required in cases of neurovascular compromise or significant fracture displacement. In children and adolescents, these injuries mostly consist of physeal separations, which have a large healing potential and can therefore be managed conservatively. Current concepts of clavicle fracture management are discussed including surgical indications, techniques, and results.

Management of multidirectional instability of the shoulder.

Multidirectional shoulder instability is defined as symptomatic instability in two or more directions. Instability occurs when static and dynamic shoulder stabilizers become incompetent due to congenital or acquired means. Nonspecific activity-related pain and decreased athletic performance are common presenting complaints. Clinical suspicion for instability is essential for timely diagnosis. Several examination techniques can be used to identify increased glenohumeral translation. It is critical to distinguish increased laxity from instability. Initial management begins with therapeutic rehabilitation. If surgical management is required, capsular plication has been used successfully. Advanced arthroscopic techniques offer several advantages over traditional open approaches and may have similar outcomes. The role of rotator interval capsular plication is controversial, but it may be used to augment capsular plication in patients with specific patterns of instability. Despite encouraging results, outcomes remain inferior to those associated with traumatic unidirectional instability.

Arthroscopic trans-capsular axillary nerve decompression: indication and surgical technique.

Symptomatic axillary nerve compression is rare yet results in debilitating pain, weakness, and decreased athletic performance in some patients. If nonoperative modalities fail, surgical intervention is necessary to reduce symptoms and avoid functional decline. Traditionally, open techniques have been described to decompress the axillary nerve and are reported to provide satisfactory results. Similar to suprascapular nerve decompression, recent advances have provided the opportunity to develop all-arthroscopic axillary nerve decompression techniques. Although direct comparisons between open and arthroscopic techniques do not exist, arthroscopic axillary nerve decompression may provide some benefits over open techniques. Therefore we present a technique and early results for all-arthroscopic trans-capsular axillary nerve decompression.

Arthroscopic management of glenohumeral arthrosis: humeral osteoplasty, capsular release, and arthroscopic axillary nerve release as a joint-preserving approach.

Glenohumeral arthrosis frequently results in substantial discomfort and activity limitations. Shoulder arthroplasty has been shown to provide reliable pain relief under these circumstances in older, less active populations. Younger patients, however, who desire to continue participation in high-demand activities, may not be optimal candidates for glenohumeral arthroplasty. Arthroscopic debridement has been reported to provide incomplete symptomatic relief in this cohort of patients. It is evident from cadaveric studies that the axillary nerve runs in close proximity to the inferior glenohumeral capsule. An inferior humeral osteophyte of sufficient size may compress the axillary nerve and potentially contribute to posterior shoulder pain in a manner similar to quadrilateral space syndrome. Therefore we present a technique for and early results of the arthroscopic management of glenohumeral arthrosis in young, high-demand patients. This technique combines traditional glenohumeral debridement and capsular release with inferior humeral osteoplasty and arthroscopic transcapsular axillary nerve decompression. In the appropriate patient, these additions may provide symptomatic relief that is greater than that with simple debridement alone.

Technical aspects of anterior cruciate ligament reconstruction for the general orthopaedic surgeon.

Anterior cruciate ligament reconstruction is the sixth most common procedure performed by orthopaedic surgeons. The goals of the procedure are to restore knee stability and patient function. These goals are dependent on proper graft positioning and incorporation. Anterior cruciate ligament reconstruction involves a technically complicated series of steps, all of which affect graft healing and clinical outcome. A wide variety of graft choices and surgical techniques are currently available for use. It is important for orthopaedic surgeons performing anterior cruciate ligament reconstructions to be aware of the indications for graft selection, techniques for correct graft placement, and the biologic implications related to these factors.

Acromioclavicular joint injuries: anatomy, diagnosis, and treatment.

Acromioclavicular (AC) joint injuries are common in athletic populations and account for 40% to 50% of shoulder injuries in many contact sports, including lacrosse, hockey, rugby and football. The AC joint is stabilized by static and dynamic restraints, including the coracoclavicular (CC) ligaments. Knowledge of these supporting structures is important when identifying injury and directing treatment. Management of AC injuries should be guided by severity of injury, duration of injury and symptoms, and individual patient factors. These help determine how best to guide management, and whether patients should be treated surgically or nonsurgically. Treatment options for AC injuries continue to expand, and include arthroscopic-assisted anatomic reconstruction of the CC ligaments. The purpose of this article is to review the anatomy, diagnostic methods, and treatment options for AC joint injuries. In addition, the authors' preferred reconstruction technique and outcomes are presented.

Multimedia article. The rotator interval: pathology and management.

The rotator interval describes the anatomic space bounded by the subscapularis, supraspinatus, and coracoid. This space contains the coracohumeral and superior glenohumeral ligament, the biceps tendon, and anterior joint capsule. Although a definitive role of the rotator interval structures has not been established, it is apparent that they contribute to shoulder dysfunction. Contracture or scarring of rotator interval structures can manifest as adhesive capsulitis. It is typically managed nonsurgically with local injections and gentle shoulder therapy. Recalcitrant cases have been successfully managed with an arthroscopic interval release and manipulation. Conversely, laxity of rotator interval structures may contribute to glenohumeral instability. In some cases this can be managed with one of a number of arthroscopic interval closure techniques. Instability of the biceps tendon is often a direct result of damage to the rotator interval. Damage to the biceps pulley structures can lead to biceps tendon subluxation or dislocation depending on the structures injured. Although some authors describe reconstruction of this tissue sling, most recommend tenodesis or tenotomy if it is significantly damaged. Impingement between the coracoid and lesser humeral tuberosity is a relatively well-established, yet less common cause of anterior shoulder pain. It may also contribute to injury of the anterosuperior rotator cuff and rotator interval structures. Although radiographic indices are described, it appears intraoperative dynamic testing may be more helpful in substantiating the diagnosis. A high index of suspicion should be used in association with biceps pulley damage or anterosuperior rotator cuff tears. Coracoid impingement can be treated with either open or arthroscopic techniques. We review the anatomy and function of the rotator interval. The presentation, physical examination, imaging characteristics, and management strategies are discussed for various diagnoses attributable to the rotator interval. Our preferred methods for treatment of each lesion are also discussed.

Open Reduction and Internal Fixation of Intra-Articular Calcaneal Fractures Via an Extensile Lateral Approach.

INTRODUCTION: Although displaced intra-articular calcaneal fractures were historically treated nonoperatively because of unreliable outcomes, they are now commonly treated with open reduction and internal fixation (ORIF). STEP 1 PREOPERATIVE PLANNING AND OPERATIVE SETUP: Coronal images are most helpful. STEP 2 INCISION AND SOFT-TISSUE MANAGEMENT: Elevate the flap using the "no-touch" technique to minimize wound complications. STEP 3 REDUCE POSTERIOR FACET AND PERFORM PROVISIONAL STABILIZATION: Achieve anatomic reduction of the medial calcaneal wall before proceeding with the remainder of the fracture reduction. STEP 4 APPLY LAG FIXATION AND A LATERAL NEUTRALIZATION PLATE: Use a traditional nonlocking plate and be sure that at least one lag screw achieves purchase. STEP 5 CLOSE WOUND: Use the "no-touch" technique, with the goal of tension-free wound closure. STEP 6 POSTOPERATIVE CARE: Watch closely for drainage or delayed healing. RESULTS & PREOP/POSTOP IMAGES: ORIF is a viable treatment option for displaced intra-articular calcaneal fractures without contraindication for older patients. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Recurrent compartment syndrome: 2 cases and a review of the literature.

Compartment syndrome is a potentially devastating entity, and timely recognition is critical for appropriate management. Diagnosis is classically a clinical one and based largely on serial examinations. When clinical examinations are compromised, compartment pressure monitoring may be useful. These diagnostic measures, however, assume recognition of "at-risk" injuries or clinical scenarios. Rarely discussed is whether an open fasciotomy provides any degree of protection from redeveloping compartment syndrome. To this end, we present 2 cases of recurrent compartment syndrome after previous fasciotomy. These reports illustrate a previously unreported at-risk population and demonstrate that compartment syndrome can recur in a previously released compartment. Therefore, prior fasciotomy should not be considered protective against acute compartment syndrome. These patients should be evaluated and managed no differently from patients with primary compartment syndrome.