Shoulder Surgery

Arthroscopically assisted latissimus dorsi transfer is a viable option for treatment of patients in their 50s to 70s, without arthritis of the glenohumeral joint, who suffer from massive rotator cuff tears that are not amendable to primary repair due to fatty changes in the muscle tissue, or that have failed previous repair attempts. This procedure offers immediate and dramatic pain relief and is not as technically demanding as one might think. Understanding and respecting the principles of tendon transfer is a key to the success of this procedure.

Background and Purpose:The Stanmore Percentage of Normal Shoulder Assessment (SPONSA) is a patient-reported outcome measure (PROM). The score assesses pain, range of movement, strength, stability and function of the shoulder. The aim of this work was to formally validate the SPONSA. Materials and Methods: Validation of this score was carried out by measuring reproducibility, construct validity and sensitivity to change. Time to completion was also recorded. The Oxford Shoulder Score (OSS) and Constant Score (CS) were used for comparison. These assessments were performed with 61 individuals undergoing shoulder interventions. Results: There was excellent preoperative reproducibility in both intra-and inter-observer groups. The SPONSA had a 0.79 correlation with the OSS and 0.78 with the CS. The overall effect size of the SPONSA was 0.72, which was comparable to OSS (0.65) and greater than CS (0.34), implying equal or better sensitivity to change. Conclusions: The SPONSA is practical and quick to perform and also a reproducible and a sensitive instrument. This simple PROM is a commendable addition to the existing validated scoring methods for the shoulder. Level of Evidence: I;; testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

} Muscle activation patterns in patients with recurrent shoulder instability } Symptomatic chronic long head of biceps rupture: Surgical results } Does age or gender of the patient influence the outcome of type II superior labrum anterior and posterior repair? } Surgical treatment of lateral clavicle fractures associated with complete coracoclavicular ligament disruption: Clinico-radiological outcomes of acromioclavicular joint sparing and spanning implants } Septic failure is not a septic loosening: A case report of a failed shoulder prosthesis } Locking plates for displaced fractures of the lateral end of clavicle: Potential pitfalls } Improved clinical utility in clavicle fracture decision-making with true orthogonal radiographs C o n t e n t s ABSTRACT Purpose: The aim of this study is to present muscle patterns observed with the direction of instability in a series of patients presenting with recurrent shoulder instability. Materials and Methods: A retrospective review was carried out on shoulder instability cases referred for fine wire dynamic electromyography (DEMG) studies at a specialist upper limb centre between 1981 and 2003. An experienced consultant clinical neurophysiologist performed dual needle insertion into four muscles (pectoralis major (PM), latissimus dorsi (LD), anterior deltoid (AD) and infraspinatus ) in shoulders that were suspected to have increased or suppressed activation of muscles that could be contributing to the instability. Raw EMG signals were obtained while subjects performed simple uniplanar movements of the shoulder. The presence or absence of muscle activation was noted and compared to clinical diagnosis and direction of instability. Results: A total of 140 (26.6%) shoulders were referred for fine wire EMG, and 131 studies were completed. Of the shoulders tested, 122 shoulders (93%) were identified as having abnormal patterns and nine had normal patterns. PM was found to be more active in 60% of shoulders presenting with anterior instability. LD was found to be more active in 81% of shoulders with anterior instability and 80% with posterior instability. AD was found to be more active in 22% of shoulders with anterior instability and 18% with posterior instability. IS was found to be inappropriately inactive in only 3% of shoulders with anterior instability but in 25% with posterior instability. Clinical assessment identified 93% of cases suspected to have muscle patterning, but the specificity of the clinical assessment was only correct in 11% of cases.

This is a unique case of a female patient with features of classical and hypermobile types of Ehlers-Danlos syndrome (EDS) who developed complex scapular winging from spinal accessory and long thoracic neuropathies. These neurological problems became manifest after an uncomplicated total shoulder arthroplasty (TSA). The patient had a complex postoperative course with extensive work-up in addition to revision shoulder surgery and manipulations to treat shoulder stiffness. It was eventually suspected that the periscapular nerve impairments occurred during physical therapy sessions after her TSA. This interpretation was further supported by genetic evidence that, in addition to EDS, the patient had an unrecognized genetic propensity for nerve palsies from stretch or pressure ("hereditary neuropathy with liability to pressure palsies" (HNPP)). By two years after the TSA the neuropathies had only partially improved, leaving the patient with persistent scapular winging and shoulder weakness. With this case we alert surgeons and physical therapists that patients with EDS can have not only a complicated course after TSA, but rare concurrent conditions that can further increase the propensity of neurological injuries that result in compromised shoulder function.

Purpose: The purpose of this study is to report the early and midterm functional outcomes and complications of a consecutive series of patients with primary adhesive capsulitis who were treated with isolated anteroinferior arthroscopic capsular release after they did not respond to conservative treatment. Methods: Thirty-two consecutive patients with idiopathic adhesive capsulitis who did not respond to conservative physiotherapy were included in the study. Arthroscopic anteroinferior capsular release was performed in all cases. The primary outcome was improvement in range of motion in the short-and midterm follow-up. We also evaluated pain relief with the visual analog scale, functional outcomes with the ConstanteMurley score, and we registered postoperative complications. Results: The mean age was 49.6 years (range, 33-68 years) and the mean follow-up was 63 months (range, 18-84). Overall, there was significant improvement in the ConstanteMurley score from 42.4 to 86 points (P < .001). The visual analog scale decreased by approximately 6.3 points compared with the preoperative value (P < .001). All parameters improved significantly the first 6 months and then remained stable until the end of follow-up (P < .001). There was an additional minor improvement in both parameters between the sixth month and the final follow-up; however, this improvement was less than in the first 6 months and it was not statistically significant. Conclusions: In patients who don't respond to conservative treatment for primary adhesive capsulitis, isolated anteroinferior capsular release provides a reliable improvement in pain and range of motion that is maintained in the mid-term follow-up. Level of Evidence: Level IV, therapeutic, case series study.

Background: The present study aims to add to the body of evidence delineating the learning curve for a shoulder surgeon to become proficient in focussed ultrasound for the detection of full-thickness rotator cuff tears, as well as to describe a learning method for this skill. Methods: Consecutive patients who were scheduled to undergo an arthroscopy for rotator cuff disease were scanned immediately before surgery by a senior shoulder surgeon with limited previous experience of shoulder ultrasound. The presence or absence of a full-thickness rotator cuff tear on scan was compared with intra-operative findings as the gold standard. Results: Two hundred and ten shoulders were scanned over three equal learning periods. Comparing predictive values from the first to the third training period, sensitivity improved from 0.86 to 0.95, specificity from 0.92 to 0.98, negative predictive value from 0.94 to 0.98, and positive predictive value from 0.82 to 0.95. Conclusions: The high predictive values obtained in the present study for surgeon-led detection of cuff tears using ultrasound are comparable with those quoted for musculoskeletal radiologists in the literature. The present study adds evidence that a shoulder surgeon can achieve accelerated learning of this skill and offers some potentially time-saving and patient-friendly alternatives to existing guidelines.

Background: Deep infection following shoulder surgery is a rare but devastating problem. The use of an effective skinpreparation solution may be an important step in preventing infection. The purposes of the present study were to examine the native bacteria around the shoulder and to determine the efficacy of three different surgical skinpreparation solutions on the eradication of bacteria from the shoulder.

The aim of our study was to evaluate the
shoulder function after clavicular hook plate fixation of
acute acromioclavicular dislocations (Rockwood type III)
in a population group consisting exclusively of high-demand
military personnel. This prospective study was carried
out at a tertiary care military orthopaedic centre during
2012–2013 using clavicular hook plate for management of
acromioclavicular injuries without coracoclavicular ligament
reconstruction in 33 patients. All patients underwent
routine implant removal after 16 weeks. The functional
outcome was assessed at 3, 6 and 12 months after hook
plate removal and 2 years from the initial surgery using the
Constant Murley and UCLA Scores. All the patients were
male serving soldiers and had sustained acromioclavicular
joint dislocation (Rockwood type III). Mean age of the
patient group was 34.24 years (21–55 years). The mean
follow-up period in this study was 23.5 months
(20–26 months) after hook plate fixation and an average of
19.9 months (17–22 months) after hook plate removal. The
average Constant Score at 3 months after hook plate
removal was 60.3 as compared to 83.7 and 90.3 at
6 months and 1 year, respectively, and an average of 91.8
at the last follow-up that was approximately 2 years after
initial surgery which was statistically significant (p value
\0.05). The UCLA Score was an average of 15.27, 25.9
and 30.1 at 3, 6 months and 1 year, respectively, after
removal of hook plate which improved further an average
of 32.3 at the last follow-up, which was also statistically
significant (p value\0.05). Clavicular hook plate fixation
without coracoclavicular ligament reconstruction is a good
option for acute acromioclavicular dislocations producing
excellent medium-term functional results in high-demand
soldiers.

} Coracoid bone graft osteolysis after Latarjet procedure: A comparison study between two screws standard technique vs mini-plate fixation } A biomechanical assessment of superior shoulder translation after reconstruction of anterior glenoid bone defects: The Latarjet procedure versus allograft reconstruction } Beyond the peak of the anterior glenoid rim: A cadaveric study } Ossification of the suprascapular ligament: A risk factor for suprascapular nerve compression? } Digital photography for assessment of shoulder range of motion: A novel clinical and research tool } Supraspinatus and infraspinatus compartment syndrome following scapular fracture } Arthroscopic autograft reconstruction of the inferior glenohumeral ligament: Exploration of technical feasibility in cadaveric shoulder specimens } Metal markers for radiographic visualization of rotator cuff margins: A new technique for radiographic assessment of cuff repair integrity C o n t e n t s ABSTRACT Aims:

Background: The suprascapular nerve, derived from the upper trunk of the brachial plexus passes through the suprascapular notch into the supraspinous fossa where it supplies the supraspinatus and then through the spinoglenoid notch to gain entry into the infraspinous fossa where it innervates the infraspinatus muscle. The nerve may be compressed at either of these two notches or injured in operations around the shoulder. Knowledge of the location of the nerve in these notches in relation to fixed bony landmarks around the shoulder is important in avoiding iatrogenic injury to the nerve or to locate it for release when it is compressed or for anaesthetic blockade.

Objective: To determine the distances between the suprascapular and spinoglenoid notches and fixed bony landmarks in the shoulder i.e the acromion, the supraglenoid tubercle, the posterior edge of the glenoid rim and the tip of the coracoid process.

Methods: The distances were measured using digital vernier callipers on dried unpaired adult scapulae that were grossly not deformed. The mean, minimum, maximum and standard deviation of the measurements was obtained.

Results: Average distance to the suprascapular notch from the supraglenoid tubercle, anterolateral edge of the acromion and the tip of the coracoid process were 31.2mm, 65.6mm and 45.7mm respectively. Average distance to the spinoglenoid from the posterior glenoid rim was 16.3mm.

Conclusion: Comparison with other populations shows variability in these distances. In order not to imperil the suprascapular nerve in the suprascapular incisure, a safe distance of less than 25.5mm from the supraglenoid tubercle should be observed. In the spinoglenoid notch, a safe distance of less than 13.1mm from the edge of the posterior glenoid rim should be maintained.

Keywords: Suprascapular nerve, Suprascapular notch, Spinoglenoid notch, Acromion, Coracoid process

A thromboelastometric profile and standard laboratory tests (hemoglobin, platelets count, PT, aPTT, fibrinogen) were performed in the same timeon patient venous blood and on unwashed salvaged blood in the PACU.Results. – Twenty patients were included. The median duration of surgery was 93 minutes. Thirteen patients (65%) received tranexamic acid duringprocedure. The median volume of shed blood was 225 mL. Two patients (10%) received a reinfusion. Analysis of shed blood showed a majordeficiency of clotting factor in standard biology (PT < 10%) and an absence of clot formation in thromboelastometric test (In-tem®, Ex-tem®,Fib-tem®or Ap-tem®). Compared to venous blood, shed blood had significantly lower hemoglobin levels: 8.8 vs 13.5 g/dL (P < 0.0001). Allogenictransfusion concerned 5% of patients.Discussion. – In this work, we confirmed that shed blood was naturally uncoagulable probably due to a multifactorial mechanism involving a majorclot factor deficiency and an activation of fibrinolysis.