Anterior deltoid reeducation for irreparable rotator cuff tears revisited.

BACKGROUND: A previous study introduced a method of conservative treatment of irreparable rotator cuff tears (RCTs) using a rehabilitation program (anterior deltoid reeducation [ADR]). The purposes of this study were to present our experience with ADR and to compare our results with those of the previous study. METHODS: Thirty consecutive elderly patients with irreparable RCTs were prospectively enrolled and taught how to perform the home-based ADR program for a period of 3 months. Clinical and radiographic evaluations were determined at the first visit. Clinical follow-up was available after 9 and 24 months. Failure of the ADR program was defined as abandonment of the ADR program because of pain and/or a patient's decision to undergo surgery at any time or a less than 20-point improvement in the American Shoulder and Elbow Surgeons score at last follow-up. RESULTS: Of the 30 patients, 9 did not complete the 3-month ADR program because of pain. Of the 21 patients who completed the ADR program, 3 were not satisfied with the outcome and went on to undergo surgery. Eighteen of the 30 patients completed the program and had a follow-up at 24 months. Among these 18 cases, there were significant mean improvements between pre-ADR and follow-up outcome scores among all variables (P < .005). However, 6 of these 18 patients did not have an improvement in the American Shoulder and Elbow Surgeons score by at least 20 points. Overall, the ADR program had a success rate of only 40%. CONCLUSION: A 3-month ADR program had limited success to treat irreparable RCTs. We could not reproduce the high rate of satisfactory results of 82% found in a previous study.

Comparison of the subjective elbow value and the Mayo elbow performance score.

BACKGROUND: The aim of this study was to evaluate the subjective elbow value (SEV) and compare it with the Mayo Elbow Performance Score (MEPS). The SEV is defined as the patient's subjective estimation of the elbow as a percentage of a normal elbow, which would correspond to 100%. METHODS: The MEPS and the SEV were prospectively assessed in all patients treated for any elbow pathology. Two groups in this consecutive series were analyzed: (1) all first consultations (n = 241) and (2) all patients who had a preoperative consultation, a surgical procedure, and a postoperative consultation (n = 41). Statistical analysis included calculation of correlation and responsiveness of the scores. RESULTS: For the first consultations, the mean MEPS and SEV were 65 points and 60%, respectively. Both scores correlated (r = 0.671). The strongest correlation was found for female patients (r = 0.733) and for the diagnosis group of joint damage (r = 0.747). The standardized response means were 1.26 for the MEPS and 1.01 for the SEV, indicating that both scores detected an obvious change in the outcome. CONCLUSIONS: The SEV is an easily administered, responsive, valid tool to assess the condition of the elbow. It should be considered an adjunct to currently used scores because it only detects the subjective condition of the elbow.

Injection-induced low-grade infection of the shoulder joint: preliminary results.

BACKGROUND: Purulent arthritis of the shoulder has been widely reported. Low-grade post-operative infections of the shoulder have also been observed. Low-grade infections of the shoulder without prior surgery have not been reported in the literature. The purpose of this study is to present our experience of seven patients with low-grade infections of the shoulder without a history of prior surgery. METHODS: We retrospectively reviewed seven patients, mean age of 45 years that originally presented with diffuse shoulder pain, with or without stiffness. None had prior surgery but all had prior injections, average 5.6, into the shoulder. All patients were treated with various arthroscopic procedures. All had harvesting of four tissue probes identifying low-grade infection. Pre/post-operative pain score, pre/post-operative range of motion, intraoperative findings, post-operative Constant score, Subjective Shoulder Value and pre/post operative radiographs were analyzed. Post-operative antibiotic therapy was recorded. RESULTS: All patients showed synovitis without pus or any other sign of infection. Propionibacterium acnes were identified in five, coagulase-negative Staphylococcus in two, and Staphylococcus saccharolyticus in one shoulder. One patient had a mixed infection (Propionibacterium acnes and coagulase-negative Staphylococcus). Therapy consisted of oral antibiotics for 1-6 months. Four patients had a satisfactory and three an unsatisfactory outcome. CONCLUSIONS: Diffuse shoulder pain with or without stiffness in patients without prior surgical history can be caused by low-grade infection. Treatment using oral antibiotics has unpredictable outcomes. Further studies are necessary to analyze this pathology. LEVEL OF EVIDENCE: Level IV, retrospective case series, treatment study.

Rotator cuff tears treated with a modified deltoid flap repair technique.

BACKGROUND: Few options exist in the treatment of irreparable rotator cuff tears, especially in younger patients. The purpose of this study was to present our experience with deltoid flap repairs combined with acromion elevation osteotomy increasing the space for the flap. METHODS: We retrospectively reviewed the outcome of 57 patients with a mean age of 60 years who had undergone the modified anterolateral deltoid flap technique for the treatment of large and massive rotator cuff tears. Follow-up was performed after a mean of 6 years. RESULTS: At follow-up, 84% of patients considered the condition of their shoulder as better or much better compared with before surgery. The mean Constant score was 88% (range, 45-122). Before surgery, all shoulders were significantly painful. At latest follow-up, 91% of the patients had no or mild pain. Elevation of the arm above 90° was possible in 38 patients before surgery and in 53 patients at latest follow-up. Tears involving 3 tendons were associated with inferior results. Retears of the deltoid flap occurred in 8 patients (14%); 1 of them was successfully treated with a reverse total shoulder replacement, and 6 had a repair of the flap, with only 1 satisfactory outcome. CONCLUSIONS: The modified deltoid flap yielded reliable pain relief and a high rate of patient satisfaction, as well as satisfactory function in the majority of the patients. Especially in younger patients, this technique might be considered a viable alternative for the treatment of irreparable rotator cuff tears.

Non-purulent low-grade infection as cause of pain following shoulder surgery: preliminary results.

Low-grade infection was systematically searched for in all revision shoulder surgeries by harvesting tissue samples. Ten consecutive patients were identified with a non-purulent low-grade infection of the shoulder. All of these patients suffered from pain and eight were stiff. Preoperative aspiration in eight patients yielded bacterial growth in only one case. Serum C-reactive protein levels were normal in seven out of 10 cases. Propionibacterium acnes was identified in seven, coagulase-negative Staphylococcus in two and Staphylococcus saccharolyticus in one case. The delay between harvesting the tissue samples and detection of bacterial growth averaged eight days (range, 2-17). After debridement and antibiotic treatment for a mean of 4.5 months, tissue samples were repeatedly harvested in nine patients due to persistent pain. The infection was microbiologically eradicated in six out of nine cases that had a repeated biopsy. However, nine out of 10 patients continued to suffer from moderate to severe pain. Low-grade infection of the shoulder can be a cause of persistent pain and stiffness. The results of antibiotic treatment are disappointing. Further studies are necessary to analyse this difficult pathology.

Total elbow arthroplasty for posttraumatic arthrosis.

Total elbow arthroplasty can be effective in treating acute injuries and posttraumatic conditions of the elbow, although typically it is considered a salvage procedure. The ideal prosthetic implant appears to be linked and semiconstrained, with an anterior flange to resist posterior and rotatory forces. The ability to fix the stem without condyle preservation is important in treating a posttraumatic condition. The results of total elbow arthroplasty can deteriorate over time because of periprosthetic fracture, implant fracture, bushing wear, or other mechanical failure. The rate of aseptic loosening is less than 10% after 10 years, which is lower than had been anticipated. Elbow replacement can be extremely effective for a properly selected patient with posttraumatic arthrosis. However, approximately 25% of patients have a complication.

Malpositioning of radial head prostheses: an in vitro study.

Nonanatomic insertion of radial head prostheses may result in maltracking and capitellar erosion. The purpose of this study was to analyze the ability to perform anatomic radial head replacement and to study radiocapitellar prosthetic subluxation under unstable conditions. In vitro measurements were performed in 10 intact elbows and after insertion of radial head prostheses (rigid uncemented, rigid cemented, bipolar). The diameter and length of the proximal radius were approximately restored. However, prosthesis-shaft malalignment, up to 21 degrees , was observed frequently. A posterolateral rotatory stress after resection of 50% of the coronoid caused a mean radiocapitellar subluxation of more than 30% for the rigid prostheses, whereas bipolar devices self-aligned with a mean subluxation similar to intact elbows. In conclusion, it was not possible to consistently insert radial head prostheses anatomically. Marked radiocapitellar subluxation occurred for the rigid but not for the bipolar implants. Clinical trials are needed to analyze these findings.

No effect of forearm band and extensor strengthening exercises for the treatment of tennis elbow: a prospective randomised study.

The objective of this prospective randomised study was to analyse the effect of the forearm support band and of strengthening exercises for the treatment of tennis elbow. Twenty-nine patients with 30 tennis elbows were randomised into 3 groups of treatment: (I) forearm support band, (II) strengthening exercises and (III) both methods. The patients had a standardised examination at their first visit, and then after 6 weeks, 3 months and 1 year. At the latest follow-up, there was a significant improvement of the symptoms compared to before treatment (p<0.0001), considering all patients independently of the methods of treatment. However, no differences in the scores were found between the 3 groups of treatment (p=0.27), indicating that no beneficial influence was found either for the strengthening exercises or for the forearm support band. Improvement seems to occur with time, independent of the method of treatment used.

Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: a study in thirteen patients.

In 13 patients, the development of supraspinatus muscle atrophy and fatty infiltration after rotator cuff tendon repair was quantified prospectively via magnetic resonance imaging. Intraoperative electrical nerve stimulation at repair showed that the maximal supraspinatus tension (up to 200 N) strongly correlated with the anatomic cross-sectional muscle area and with muscle fatty infiltration (ranging from 12 N/cm(2) in Goutallier stage 3 to 42 N/cm(2) in Goutallier stage 0). Within 1 year after successful tendon repair (n = 8), fatty infiltration did not recover, and atrophy improved partially at best; however, if the repair failed (n = 5), atrophy and fatty infiltration progressed significantly. The ability of the rotator cuff muscles to develop tension not only correlates with their atrophy but also closely correlates with their degree of fatty infiltration. With current repair techniques, atrophy and fatty infiltration appear to be irreversible, despite successful tendon repair. Unexpectedly, not only weak but also very strong muscles are at risk for repair failure.

Coonrad-Morrey total elbow replacement for primary and revision surgery: a 2- to 7.5-year follow-up study.

In this study, 23 patients were treated with the Coonrad-Morrey total elbow prosthesis for posttraumatic arthrosis (15 cases), acute distal humeral fracture (1 case), inflammatory arthritis (3 cases), and revision of another type of total elbow prosthesis (4 cases). After a mean follow-up of 4 years (range, 2-7.5 years) or at revision as a result of loosening or infection, 78% had a satisfactory outcome according to the Mayo Elbow Performance Score. Of the patients, 16 (70%) had no or mild pain and 7 had moderate to severe pain. The loosening rate was 17%. Possible risk factors for loosening were poor cementing and anterior coronoid impingement. Of the patients, 10 (43%) had complications and 7 of these (30%) required revision surgery. The Coonrad-Morrey total elbow prosthesis can lead to successful outcomes for difficult elbow pathologies. However, the complication rate was higher in our series than previously reported. Some technical aspects for use of this implant are outlined.

Debridement of extensors and drilling of the lateral epicondyle for tennis elbow: a retrospective follow-up study.

Twenty-one patients treated for tennis elbow with debridement of the extensors, without repair of the affected tendons, and with decortication by drilling of the lateral epicondyle were reviewed retrospectively after a mean follow-up of 15 months (range, 11-33 months). The early postoperative period was characterized by a painful and slow recovery. At latest follow-up, 17 patients (81%) had a satisfactory outcome with no or only mild pain. Of the patients, 20 (95%) felt that they were better or much better compared with preoperatively. There were 2 complications: 1 hematoma that was aspirated and 1 temporary frozen shoulder. Debridement of the extensors and drilling of the lateral epicondyle relieved pain and restored function in the majority of the patients. However, recovery was slow and was never found to be immediate as described in other series of tennis elbow procedures where the extensors were simply released and the lateral epicondyle was not decorticated.

Arthroscopic posterior portal closure.

Posterior "working" portals in arthroscopic posterior stabilization could result in defects of the posterior capsule if not repaired. We describe a single portal technique used to close the posterior portal defect after arthroscopic stabilization. It is a safe and easy-to-perform technique, which could strengthen the structural integrity of the repair.

In vitro comparison of standard and Knotless metal suture anchors.

PURPOSE: Clinical experience after failed Knotless suture anchor (Mitek, Westwood, MA) fixations suggested that the Knotless anchor provides considerably less fixation stability than a standard metal anchor. The purpose of this study was to analyze soft tissue fixation to bone comparing a standard and a Knotless metal suture anchor. TYPE OF STUDY: In vitro study. METHODS: The Mitek GII and Mitek Knotless suture anchors were tested on 7 human cadaveric fresh-frozen glenoids. The anchors were inserted into the glenoid rims, and the sutures of the anchors were fixed to a metal hook attached to the cross-head of a testing machine. Cyclic loading was performed. The gap formation between the metal hook and the glenoid rim, the ultimate failure loads and the modes of failure were determined. RESULTS: The mean gap formation was significantly greater for the Knotless anchor (3.8 +/- 1.4 mm) than for the GII anchor (2.4 +/- 0.5 mm) after 25 cycles with 50 N repeated load (P =.04). The largest gap of a Knotless fixation was 5.3 mm compared with 3.0 mm for the GII. The ultimate failure load was not significantly different for the Knotless anchor (179 N) and for the GII anchor (129 N). Both anchors failed by either rupture of the suture material or by pullout of the anchors. CONCLUSIONS: The GII anchor allows significantly less displacement than the Knotless anchor. Ultimate tensile strength and mode of failure are similar. Greater displacement results in larger gap formation between the soft tissue and the bone. This might weaken and jeopardize the repair. CLINICAL RELEVANCE: If reattached soft tissues are subjected to postoperative loading, gap formation may result when using the Knotless anchor. For these conditions, suture fixation with knots may be used instead.

Coronoid process and radial head as posterolateral rotatory stabilizers of the elbow.

BACKGROUND: The purpose of this study was to evaluate the role of the radial head and the coronoid process as posterolateral rotatory stabilizers of the elbow and to determine the stabilizing effect of radial head replacement and coronoid reconstruction. METHODS: The posterolateral rotatory displacement of the ulna was measured after application of a valgus and supinating torque (1). in seven intact elbows, (2). after radial head excision, (3). after sequential resection of the coronoid process, (4). after subsequent insertion of each of two different types of metal radial head prostheses (a rigid implant and a bipolar implant with a floating cup), and (5). after subsequent reconstruction of the coronoid with each of two different techniques in the same cadaveric elbow. RESULTS: The posterolateral rotatory laxity averaged 5.4 degrees in the intact elbows. The surgical approach used in this study insignificantly increased the mean laxity to 9 degrees. Excision of the radial head in an elbow with intact collateral ligaments caused a mean posterolateral rotatory laxity of 18.6 degrees (p < 0.0001). Additional removal of 30% of the height of the coronoid fully destabilized the elbows, always resulting in ulnohumeral dislocation despite intact ligaments. Implantation of a rigid radial head prosthesis stabilized the elbows. However, a mean laxity of 16.9 degrees persisted after insertion of a floating prosthesis (p < 0.0001). The elbows with a defect of 50% or 70% of the coronoid, loss of the radial head, and intact ligaments could not be stabilized by radial head replacement alone, but additional coronoid reconstruction restored stability. CONCLUSIONS: The results of this study suggest that the coronoid and the radial head contribute significantly to posterolateral rotatory stability.

Articular cartilage lesions of the glenohumeral joint: diagnostic effectiveness of MR arthrography and prevalence in patients with subacromial impingement syndrome.

PURPOSE: To determine the prevalence of articular cartilage lesions in patients with subacromial impingement syndrome and to assess the diagnostic effectiveness of magnetic resonance (MR) arthrography in detecting such cartilage abnormalities. MATERIALS AND METHODS: MR arthrographic images obtained in 52 consecutive patients (mean age, 45.8 years; age range, 17-73 years; 26 male and 26 female patients) were retrospectively evaluated for glenohumeral cartilage lesions. Two experienced musculoskeletal radiologists who were blinded to the arthroscopy report independently analyzed the articular cartilage. Humeral and glenoidal cartilage were assessed separately. The lesions were graded as either subtle or marked. Arthroscopic findings were the standard of reference. Sensitivity, specificity, accuracy, and interobserver agreement were calculated. RESULTS: At arthroscopy, humeral cartilage lesions were found in 15 patients (frequency, 29%). Four lesions were subtle, and 11 were marked. Cartilage lesions of the glenoid were less frequent (eight patients; frequency, 15%): Three were subtle, and five were marked. For reader 1 and reader 2, respectively, sensitivity of MR arthrography for humeral cartilage lesions was 53% and 100%, specificity was 87% and 51%, and accuracy was 77% and 65%; sensitivity for glenoidal cartilage lesions was 75% and 75%, specificity was 66% and 63%, and accuracy was 67% and 65%. Interobserver agreement for the grading of cartilage lesions with MR arthrography was fair (humeral lesions, kappa = 0.20; glenoidal lesions, kappa = 0.27). CONCLUSION: Glenohumeral cartilage lesions are found in up to one third of patients referred for MR arthrography for subacromial impingement syndrome. The performance of MR arthrography in the detection of glenohumeral cartilage lesions is moderate.

Mechanical strength of arthroscopic rotator cuff repair techniques: an in vitro study.

BACKGROUND: Retears after rotator cuff repairs occur relatively frequently and may compromise the functional result. The goal of this study was to analyze the mechanical properties following arthroscopic techniques for rotator cuff repair and to evaluate possible alternative techniques. METHODS: In the first part, five different bone anchors (the Revo screw; Mitek Rotator Cuff anchor, 5.0-mm Statak, PANALOK RC absorbable anchor, and 5.0-mm Bio-Statak) were tested in vitro under cyclic loading on five pairs of cadaveric shoulders. Then five types of arthroscopic tendon suturing instruments were tested on rotator cuff tendons. Finally, the arthroscopically performed mattress and modified Mason-Allen stitches, fixed with either the Revo screw or the Bio-Statak, were evaluated on ten pairs of human cadaveric shoulders. RESULTS: The holding strengths of the various anchors were similar, ranging from 130 to 180 N, and approximated the holding strength of knotted number-2 suture materials. The fixation of the tested anchors yielded comparable values of stiffness except for one anchor, which showed significantly greater subsidence under cyclic load (p = 0.003). All tested, commercially available arthroscopic suturing devices were unsuitable for performing a modified Mason-Allen stitch on normal supraspinatus tendons. Modification of a commercially available suture punch with a longer needle allowed us to consistently perform a modified Mason-Allen stitch. The modified Mason-Allen stitch, which has shown favorable mechanical properties in open repairs of the rotator cuff, was not found to be stronger than the mattress stitch when performed arthroscopically and used with bone anchors. When the modified Mason-Allen stitch was fixed to one anchor, it was even weaker than a mattress stitch repaired with another anchor (168 versus 228 N). Unequal loading of the two suture branches due to the more rigid modified Mason-Allen stitch may be the reason for this difference. CONCLUSIONS: Arthroscopic techniques for rotator cuff repair with use of the mattress stitch and bone anchors allow for a relatively solid fixation. The holding strength is not improved with use of the modified Mason-Allen stitch. Although a direct comparison with previous in vitro studies is not possible, the holding strength of open fixation techniques seems to be stronger. If rotator cuffs are subjected to high postoperative loading, open repair might be preferred to reduce the risk of a retear, until stronger arthroscopic fixation techniques are developed.

Anconeus arthroplasty: a new technique for reconstruction of the radiocapitellar and/or proximal radioulnar joint.

BACKGROUND: Management of posttraumatic radiocapitellar and/or proximal radioulnar joint dysfunction and pain is a challenging problem, often with more than one pathological feature, and to date there are no consistently reliable solutions. The unreliability of prosthetic replacement prompted us to develop an anconeus arthroplasty wherein the anconeus muscle is rotated into the radiocapitellar and/or proximal radioulnar joint. METHODS: Three interposition options were assessed in our laboratory and were employed clinically: interposition at the radiocapitellar joint (Type I), interposition at the radiocapitellar and proximal radioulnar joints (Type II), and proximal radioulnar interposition (wrap) (Type III). The clinical outcomes in fourteen patients who had been treated with one of the three types of anconeus interposition arthroplasty were reviewed at least two years (mean, 6.1 years) postoperatively. RESULTS: Anatomic dissection of twenty-five specimens revealed that all three applications were possible. Of the fourteen patients, twelve (all six with a Type-I interposition, three of the five with a Type-II interposition, and all three with a Type-III interposition) had a satisfactory overall subjective result. The Mayo Elbow Performance Score averaged 63 points before the surgery and 89 points after it. CONCLUSIONS: Anconeus interpositional arthroplasty offers a reasonable likelihood of improved subjective and objective function in patients with the challenging problem of radiocapitellar and/or proximal radioulnar joint dysfunction and pain after trauma, even when there is Essex-Lopresti axial instability.

Arterial vascularization of the proximal extensor carpi radialis brevis tendon.

The macroscopic arterial vascularization of the extensor carpi radialis brevis tendon was investigated in 12 elbows from cadavers to provide fundamental anatomic information of this tendon which has been associated with lateral epicondylitis. The arterial blood supply of the extensor carpi radialis brevis tendon was highly consistent. The radial recurrent artery vascularized the entire proximal tendon through direct branches to the medial and lateral border of the tendon forming a network of small vessels on the surface of the tendon. Important contributions were provided by the posterior branch of the radial collateral artery, and minor contributions were provided by the interosseous recurrent artery. The undersurface of the tendon seemed almost avascular. This observation suggests that potential hypovascular zones might be located at the undersurface of the tendon causing degeneration and partial tear of the tendon, and that this might be an etiologic factor in the pathogenesis of lateral epicondylitis. Additional microvascular studies are necessary to investigate this hypothesis.