Subscapularis Function After Total Shoulder Arthroplasty Using Lesser Tuberosity Osteotomy or Tenotomy.

INTRODUCTION: Subscapularis dysfunction is a recognized complication after total shoulder arthroplasty (TSA). However, optimal subscapularis management during TSA is controversial. Subscapularis tenotomy (ST) has been used, whereas lesser tuberosity osteotomy (LTO) has gained popularity. This study compares the clinical outcomes in patients undergoing TSA with either ST or LTO, focusing on subscapularis strength and overall function. METHODS: Records were reviewed for TSA performed from 2010 to 2016 by a single surgeon at one institution. Patient age, sex, hand dominance, and the time of follow-up were recorded. Radiographs were obtained and interpreted. Range of motion was measured and the American Shoulder and Elbow Surgeons scores obtained. A graded belly-press test was used to determine the overall subscapularis function. Subscapularis strength was measured during a resisted belly-press maneuver. Statistical analysis was performed using a paired Student t-test or Fisher exact test, with P < 0.05 determining statistical significance. RESULTS: Overall, 28 shoulders constituted the LTO group with 37 in the ST group. No difference was found regarding age, whether their surgical site was their dominant extremity, or the time to follow-up. Radiographically, all osteotomies went on to union, with one malunion noted. Range of motion was equivalent. No statistical difference was noted in subscapularis strength or in the American Shoulder and Elbow Surgeons scores. The overall subscapularis function also failed to show any notable difference. DISCUSSION: In conclusion, either LTO or ST can be used during TSA to achieve successful clinical outcomes. The method of subscapularis management did not affect the subscapularis strength or overall function.

Primary versus revision arthroscopic reconstruction with remplissage for shoulder instability with moderate bone loss.

PURPOSE: This study aims to evaluate our outcomes of arthroscopic remplissage in this setting. METHODS: A retrospective review was performed to identify patients who underwent arthroscopic remplissage of an engaging Hill-Sachs lesion along with anterior capsulolabral reconstruction for anterior glenohumeral instability with moderate glenohumeral bone loss at our institution. Thirty-five patients, with a minimum of 2 years' follow-up, were identified. We assessed the American Shoulder and Elbow Surgeons score, incidence of recurrent instability, and postoperative Rowe instability score. RESULTS: Follow-up was available for 30 patients (31 shoulders). The mean age was 24.6 years, with a mean follow-up period of 41 months. Prior instability surgery had failed in 11 patients, and they underwent capsulolabral reconstruction and remplissage ("revision surgery"). The failure rate in revision cases (36%) was significantly higher than the failure rate in primary surgery cases (0%) (P = .01). Failure resulted from trauma in all 4 patients, and none required further surgery. The mean American Shoulder and Elbow Surgeons score for all patients improved from 50 preoperatively to 91 postoperatively (P < .001), with no significant postoperative difference between primary and revision patients (P = .13). The patients with clinical failure showed nonsignificant improvement from 41 preoperatively to 72 postoperatively (P = .08). The mean postoperative Rowe score for the entire cohort was 90. The Rowe score was significantly lower in the 4 cases of failure than in the 27 non-failure cases (51 v 96, P < .001). CONCLUSIONS: In our experience, aggressive capsulolabral reconstruction with remplissage in traumatic instability patients with moderate bone loss and engaging humeral Hill-Sachs lesions yields acceptable outcomes for primary instability surgery. However, a significantly higher failure rate occurred when arthroscopic reconstruction with remplissage was performed in the revision setting. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Surface Replacement Arthroplasty of the Humeral Head in Young, Active Patients: Midterm Results.

BACKGROUND: The treatment of glenohumeral arthritis in young, active patients remains controversial. Standard total shoulder arthroplasty in this patient group has not obtained the same satisfaction rate as in older patients. One surgical option that has emerged is humeral resurfacing. HYPOTHESIS: Humeral head surface replacement arthroplasty (SRA) would provide satisfactory clinical outcomes in active patients, allowing them to maintain their normal lifestyle without activity restrictions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 2004 to 2007, all consecutive surface replacement arthroplasties of the humerus performed at the authors' institution were identified and retrospectively reviewed, and 118 patients who underwent SRA during this time were identified. This study included patients younger than 60 years who wished to maintain an active lifestyle; 52 of the 118 patients met the inclusion criteria. University of California at Los Angeles (UCLA) shoulder scores and subjective shoulder value (SSV) scores were used to measure clinical outcomes at an average follow-up of 6 years (range, 4-8 years). Of the 52 patients meeting the inclusion criteria, 48 were contacted and examined for the study, with 4 patients lost to follow-up. RESULTS: The mean postoperative UCLA score was 28.03, with 1 patient requiring revision because of pain and glenoid wear. The mean SSV was 92% (range, 0%-100%), with 3 patients restricting their activity because of the shoulder. Forty-seven of the 48 contacted patients stated that, given the option, they would have the same surgery again. One patient required revision surgery because of pain. CONCLUSION: Surface replacement arthroplasty provided reasonable results in patients younger than 60 years with high activity demands with a low rate of revision at midterm follow-up.

Comparison of partial versus complete arthroscopic repair of massive rotator cuff tears.

BACKGROUND: Complete repair of massive rotator cuff tears can be limited by tendon retraction and poor tissue quality. When a complete repair cannot be accomplished, a significant partial repair may be possible. HYPOTHESIS: A partial repair will yield comparable outcomes to complete repair of massive rotator cuff tears in this specific patient population. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All consecutive arthroscopic rotator cuff repairs done at the authors' institution over a 2-year period were identified. A retrospective chart review was performed. Inclusion criteria required that each patient have a massive rotator cuff tear (30 cm(2) or greater). Patients were categorized as either partial or complete repair. The University of California, Los Angeles (UCLA) shoulder scores were used to measure patient outcomes at an average follow-up of 24 months (10-40 months). RESULTS: Of 1128 consecutive arthroscopic rotator cuff repairs, 97 (9%) patients were noted intraoperatively to have massive tears measuring 30 cm(2) or greater. Complete repair was achieved in 52 patients, whereas partial repair was possible in 45 patients. Eleven patients were lost to follow-up. The 41 remaining patients with only partial repair achieved a postoperative mean UCLA score of 29.49, and the 45 patients with complete repair achieved a mean UCLA score of 29.64, yielding significant improvement in both the partial repair group (P = .0001) and the complete repair group (P = .0001) compared with preoperative UCLA scores. However, no statistically significant differences in postoperative outcomes were noted when the 2 groups were compared with one another (P = .89). CONCLUSION: Partial repair of massive rotator cuff tears yielded outcomes comparable with complete repair of massive tears.

Clinical results of revision shoulder arthroplasty using the reverse prosthesis.

BACKGROUND: Success of revision shoulder arthroplasty using an unconstrained prosthesis depends on an intact rotator cuff and satisfactory bone quantity. However, the reverse shoulder arthroplasty can stabilize a glenohumeral joint even in patients with rotator cuff deficiency and bone deficits, resulting in improved outcomes. MATERIALS AND METHODS: Thirty shoulders in 28 patients with a failed arthroplasty were investigated consecutively between 2005 and 2008. All shoulders had significant rotator cuff deficiency without glenoid bone loss. Revision arthroplasty using the reverse prosthesis was performed with a minimum of 2 years of follow-up. Concomitant glenoid reconstructions with tricortical iliac crest bone grafting were necessary in 12 shoulders. RESULTS: The average adjusted Constant score improved from 24% to 65% and the American Shoulder and Elbow Surgeons (ASES) score improved from 55 to 72 (P < .0001). Average active forward flexion increased from 42° to 106° (P < .0001). The average ASES pain score improved from 6.6 to 1.6 (P < .0001). The overall complication rate was 50%, and 7 patients (23%) required reoperation. Overall, 24 of 30 shoulders (80%) were very satisfied or satisfied. CONCLUSION: Reverse shoulder arthroplasty can be an efficacious salvage procedure in the management of failed arthroplasty due to rotator cuff-related instability or bone defects, or both. Structural bone grafting on the glenoid side is successful at managing large defects, producing similar or better clinical outcomes compared with patients without bone loss. Although the operation is associated with a considerable complication rate, 80% of patients were satisfied with the results of the procedure, and 29 of 30 shoulders had a stable prosthesis.

Identification and management of "floating" posterior inferior glenohumeral ligament lesions.

Recurrent posterior glenohumeral instability, although a less common clinical entity than anterior instability, must be recognized and appropriately treated for a successful outcome. Pathologic findings that may need to be addressed include posterior Bankart lesions, humeral avulsion of the posterior inferior glenohumeral ligament (PIGHL), intrasubstance ligament attenuation, and combined lesions. In this review, we present 2 patients with the same pathoanatomic findings of recurrent posterior shoulder instability secondary to posterior humeral avulsion of the glenohumeral ligament with an associated posterior Bankart lesion. This combination of pathology is referred to as a "floating PIGHL" lesion. We review both patient's preoperative clinical findings and imaging studies and detail the necessary steps for a successful repair.

Positive culture rate in revision shoulder arthroplasty.

We recognized a trend of positive cultures taken from presumably uninfected shoulders during revision arthroplasty. Owing to the indolent nature of common shoulder pathogens such as Propionibacterium acnes, these cultures often become positive several days, even weeks, after surgery. Having concern regarding the potential importance of these positive cultures, we reviewed our revision arthroplasty population to determine the rate of positive intraoperative cultures in patients presumed to be aseptic, to characterize the isolated organisms, and to determine the subsequent development of infection. We retrospectively reviewed 27 patients (28 revisions) presumed to be uninfected between April 2005 and October 2007. Intraoperative cultures were positive in eight (29%) of the 28 revisions. Propionibacterium acnes was isolated in six. Methicillin-resistant Staphylococcus aureus was isolated in one patient and coagulase-negative Staphylococcus aureus was isolated in one patient. One-year followup was available on 24 of the 28 revisions. Two of the eight culture-positive revisions had a subsequent infection develop. Cultures taken at revision surgery for failed shoulder arthroplasty are often positive, and our findings document the importance of these positive cultures. Our data confirm previous reports isolating Propionibacterium acnes as a primary pathogen in revision shoulder arthroplasty.

Hill-sachs "remplissage": an arthroscopic solution for the engaging hill-sachs lesion.

We present an arthroscopic technique used to treat traumatic shoulder instability in patients with glenoid bone loss and a large Hill-Sachs lesion. The procedure consists of an arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion. With the patient in the lateral decubitus position, a posterior portal is established at the lateral aspect of the convexity of the humeral head that is centered over the lesion. After anterior-inferior and anterior-superior portals have been established, the camera is placed in the anterior-superior portal. The Hill-Sachs lesion is freshened with a bur through the posterior portal. A cannula is inserted in the posterior portal through the deltoid but not through the infraspinatus or capsule, and an anchor is placed in the inferior aspect of the humeral lesion. A penetrating grasper is passed through the tendon and posterior capsule, 1 cm inferior to the initial portal entry site to pull 1 suture limb. A second anchor is placed superiorly, and 1 suture limb is similarly passed. The inferior suture is tied first with the knots remaining extra-articular, pulling the infraspinatus and capsule into the lesion. After completion, the Bankart lesion can then be repaired.

Acute dislocations of the adult elbow.

Despite the highly constrained nature of the elbow joint, dislocation is not uncommon. Uncomplicated (simple) dislocations are those that occur without fracture and usually can be managed successfully with closed reduction and early motion. Precise attention, however, should be given to the stability of the elbow immediately after reduction. Instability can persist in full extension and require modification in forearm rotation and limitation of full extension to maintain stability. Soft tissue injury can be severe, at times requiring surgical repair to maintain stability.

Complete tear of the radial collateral ligament of the third metacarpophalangeal joint.

Early repair of complete collateral ligament tears restores joint alignment, stability, and full passive range of motion.