Shoulder Surgery

Bakgrund Antalet kirurgiska ingrepp förväntas öka, och därmed ökar även den totala risken för komplikationer. Världshälsoorganisationen, World Health Organization, WHO, har tagit fram en Checklista att använda i samband med kirurgiska ingrepp för att minska komplikationer och öka patientsäkerheten. Syftet med föreliggande studie är att undersöka operationssjuksköterskors erfarenheter av Checklistan. Metod En pilotstudie genomfördes och fem operationssjuksköterskor intervjuades. Intervjuerna transkriberades ordagrant och en manifest kvalitativ innehållsanalys gjordes med induktiv ansats. Resultatet visar att det fanns hinder vid användning av Checklistan, det fanns en ovana vid de nya rutiner som Checklistan innebär, arbetslagets attityder påverkar användningen och att vissa i operationsteamet visade oförståelse för Checklistans syfte. Osäkerhet rådde bland operationssjuksköterskorna för när Checklistans olika faser skulle utföras samt vem som ska initiera Checklistan. Användning av Checklistan medförde trygghet för så väl patient som personal, liksom en ökad handlingsberedskap för operationssjuksköterskan. Presentation av personalen på operationssalen ansågs vara positiv för ny personal, och negativ då detta tar tid och innebär upprepning. Slutsats WHO:s Checklista är ett bra verktyg för att öka kommunikationen och därmed öka patientsäkerheten. Det fanns ett behov av att anpassa Checklistan till den egna kliniken.

Background: Isolated patellofemoral joint osteoarthritis affects approximately 10% of patients aged over 40 years and treatment remains controversial. The Femoro Patella Vialli (FPV) patellofemoral joint replacement (Wright Medical Technology, UK has been shown to restore functional kinematics of the knee close to normal. Despite its increasing popularity in recent years, there are no studies evaluating the mid-term results with an objective scoring assessment. Aims: Therefore the aim of this study was to report the clinical and radiological outcomes of FPV patellofemoral joint replacement in patients with isolated patellofemoral arthritis, from our independent districtgeneral hospital. Methods: Between 2006 and 2012, we performed 53 consecutive FPV patellofemoral arthroplasties in 41 patients with isolated patellofemoral joint osteoarthritis. The mean follow-up was 3 years. Results: Mean Oxford Knee scores improved from 19.7 to 37.7 at latest follow-up. Ninety four per cent of patients were happy or very happy with their knees. Progression of tibiofemoral osteoarthritis was seen 12% of knees. 2 knees required revision to TKR at 7 months post-operatively, which we attribute to poor patient selection. Conclusion: Our findings suggest the FPV patellofemoral prosthesis survives well and gives a good functional outcome in the medium term.

The in-hospital mortality rate after total shoulder arthroplasty (TSA) is unknown. The purpose of this study is to quantify the in-patient mortality rates and associated demographic risk factors for patients undergoing a TSA from 2005 to 2011 using a comprehensive Medicare registry database. We conducted a retrospective review of the Medicare database within the PearlDiver database. The PearlDiver database is a publicly available Health Insurance Portability and Accountability Act-compliant national database that captures 100% of the Medicare hospital data for TSA between 2005 and 2011. Using International Classification of Diseases, Ninth Revision codes for TSA we identified a dataset of patients undergoing TSA as well as a subset of those for whom there was a death discharge (i.e., in-patient death). Risk for this outcome was further quantified by age, gender and year. Linear regression was performed to identify risk factors for the primary outcome. A total of 101,323 patients und...

Background: The goal of this study was to compare the influence of an interscalene brachial plexus block (ISB) performed with either bupivacaine or levobupivacaine in conjunction with general anaesthesia (GA) on desflurane consumption, which was titrated to maintain the recovery profiles and postoperative analgesia while also keeping the bispectral index score (BIS) between 40 and 60 in patients undergoing arthroscopic shoulder surgery. Methods: Sixty patients undergoing arthroscopic shoulder surgery were prospectively randomized to receive GA with desflurane alone (group C) or in combination with a preoperative ISB by either bupivacaine 0.25 % (group B) 40 ml or levobupivacaine 0.25 % (group L) 40 ml. BIS scores or respiratory and hemodynamic parameters during the operation, recovery characteristics, consumed doses of desflurane and pain intensities were evaluated. Results: The eye opening time was 4.0 ± 2.5 minutes for group B, 4.6 ± 2.4 minutes for group L, and 6.2 ± 2.1 minutes for group C (p < 0.05). Group B and group L saved 36 % and 25 % desflurane per unit time respectively when compared with group C (p < 0.001and p < 0.05) while the mean pain scores and analgesic requirements the first day after surgery were higher in group C (p < 0.05). Conclusions: Because of lower desflurane consumption, a superior recovery profile, and a high degree of patient acceptance, general anaesthesia in combination with interscalene block may be preferred in arthroscopic shoulder surgery. Trial registration: The trial registration number is ACTRN12613000381785

This reports presents the case of a combined clavicle fracture malunion and chronic Type IV acromioclavicular (AC) joint dislocation. The patient was seen acutely in the emergency department following a mountain bike accident at which time the clavicle fracture was identified and managed conservatively however the AC dislocation was not diagnosed. The patient presented 25 months following the injury with persistent pain and disability and was treated with clavicle osteotomy and AC stabilization. We document the clinical details, surgical treatment and outcome.

The aim of this study was to compare the effects of local infiltration analgesia and interscalene brachial plexus block techniques on postoperative pain control and shoulder functional scores in patients undergoing arthroscopic rotator cuff repair. Materials and methods: Sixty patients who underwent arthroscopic rotator cuff repair were prospectively included in the study. Patients were randomly divided into two groups. Group 1 was comprised of patients who had interscalene brachial plexus block, while group 2 was comprised of patients who had local infiltration analgesia. In group 1, interscalene block was applied with 20 mL 0.5% bupivacaine. In group 2, the Ranawat cocktail was used for local infiltration analgesia. Sixty milliliters of Ranawat cocktail was applied to the subacromial space and glenohumeral joint in equal amounts. Postoperative pain was assessed by the VAS score. Functional scores of the shoulder were also evaluated by Constant-Murley and UCLA scores. The time of first analgesic requirement and total analgesic consumption in the postoperative period were assessed. Results: The first analgesic requirement was significantly late in the interscalene brachial plexus block group (p = 0.000). There was no statistically significant difference between the groups in terms of total analgesic consumption (p = 0.204). In the postoperative 6th h, the VAS score was 2.43 in the interscalene brachial plexus block group, whereas 2.86 in the local infiltration analgesia group (p = 0.323). There was no statistically significant difference between the groups in terms of Constant-Murley shoulder and UCLA scores in the 3rd postoperative month (respectively, p = 0.929, p = 0.671). Besides, postoperative VAS scores and functional scores were negatively correlated (p < 0.01). Conclusion: Local infiltration analgesia is an effective alternative to interscalene brachial plexus block for postoperative pain management and total analgesic consumption in arthroscopic rotator cuff repair. However, the interscalene brachial plexus block provides a longer postoperative painless period.

Infection is a concern after all orthopedic procedures, including shoulder surgery. This systematic review of literature aimed to determine risk factors for infection as well as the availability and effectiveness of measures utilized to prevent infection after elective shoulder surgery. An electronic database search was performed using MEDLINE (1950-October 2017), EMBASE (1980-October 2017), CINAHL (1982-October 2017), and the Cochrane database to identify studies reporting a risk factor or preventive measure for infection after shoulder surgery. Fifty-one studies were eligible for inclusion. Risk factors identified for infection were male sex, the presence of hair, receiving an intra-articular cortisone injection within the 3 months prior to surgery, smoking, obesity, and several comorbidities. The only preventive measure with level I evidence was for the use of chlorhexidine wipes for cleansing the skin in the days prior to surgery and for the use of ChloraPrep or DuraPrep over po...

Background: The short head of biceps brachii has been the subject of little investigation when compared to the long head or distal biceps tendons. The aim of this study was to dissect and describe the origin and proximal portion of the short head of biceps brachii. Materials and Methods: Three left and two right (n=5) fresh-frozen human cadaver shoulders were dissected and the proximal short head was measured and photographed. Results: The origin of the short head of biceps consisted of muscle fibres attaching directly to the tip of the coracoid process, with a thin, tendinous aponeurosis covering its anterior surface, rather than a true tendon as previously described. Conclusion: The short head of biceps does not attach to the coracoid process via a true tendon. These findings have implications for procedures that utilise the short head of biceps.

We report the case of a patient with end-stage osteoarthritis who received a successful Copeland resurfacing hemiarthroplasty through a Mackenzie anterosuperior approach, which involves taking the anterior portion of the deltoid attachment from the acromion along with an osteo-periosteal sleeve. The patient went on to develop severe subacromial impingement symptoms 4 months postoperatively. X-rays revealed a large anteroinferior acromial osteophyte that had not been present preoperatively and was deemed to represent a malunited osteo-periosteal sleeve from the Mackenzie approach.

Introduction: Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain. Methods: This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat. Discussion: This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block.

Introduction: Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain. Methods: This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat. Discussion: This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block.

A test-retest design was used to evaluate the reliability of the self-report sections of 4 shoulder pain and disability scales. Objective: The objective of the study was to compare interitem consistency and test-retest reliability by surgical status (postoperative versus nonoperative) and to evaluate the effect of surgical status in the prediction of retest scores. Background: Patients and healthcare providers evaluate shoulder status based on self-evaluations of pain and disability. Shoulder outcome measures have been developed that include self-reports, but the properties of these measures have not been assessed by surgical status. Methods and Measures: A questionnaire containing self-report sections of 4 shoulder scales was administered to study participants twice with 1 week between administrations. The outcome measures examined were the: (1) University of California at Los Angeles (UCLA) Shoulder Score; (2) Constant-Murley Scale (CMS); (3) American Shoulder and Elbow Society (ASES) Shoulder Index; and (4) Shoulder Pain and Disability Index (SPADI). Intraclass correlation coefficients (ICC) were calculated to estimate the test-retest reliability of each of the scales and subscales. The interitem consistencies of the multi-item subscales were assessed using Cronbach's alpha. The effect of surgical status on shoulder outcome scale reliability was evaluated using a general linear models approach. Results: The interitem consistency estimates for the multi-item scales were high with both operative and nonoperative participants (0.88 to 0.96). With the exception of the satisfaction subscale of the UCLA Shoulder Score for the nonsurgical group, the estimated intraclass coefficients ranged from 0.51 to 0.91. The prediction of UCLA-satisfaction and ASES-disability, pain, and total retest scores was improved with the addition of surgical status into a regression model.

I read the article that compared the interscalene block (ISB) with the shoulder block (ShB) which is a combination of supra-scapular and axillary nerve block for shoulder arthroscopy procedures published in the current issue and wish to present my reflections on that article as a &quot;Letter to the Editor&quot; manuscript.

Objectives This is one of the manuals of East-west integrative medicine which was created by the Committee on integrative medicine of Chung-Yeon Korean Medicine Hospital. The purpose of this manual is to support clinical decision making and communication during the rehabilitation of patients after lumbar spine surgery. Methods The drafting was done by two rehabilitation specialists in Korean Medicine. After a rehabilitation specialist in western medicine reviewed the draft and exchanged their ideas, a revised version that reflects the goal of consultation was made. Then the Committee agreed to adopt the manuals through the process of review and feedback in addition to face-to-face discussions. Results This manual describes clinical decision making for rehabilitation after lumbar microdiskectomy, interbody fusion, and kyphoplasty. Therefore it contains the schedule of rehabilitation treatment through the surgical technique, general goal of the rehabilitation by phase, scales for outcome measure and postoperative infection management. Conclusions The proposal of this manual has a significance for it provides information about decision making process and contents of treatment in one medical institution for East-west integrative rehabilitation treatment after lumbar spine surgery.

Background: Although sports participation and heavy physical work can contribute to rotator cuff tears, many patients expect to return to these activities after surgery; however, irreparable rotator cuff tears can preclude this outcome. A new surgical treatmentarthroscopic superior capsule reconstruction (SCR)-restores shoulder stability and muscle balance in patients with irreparable rotator cuff tears; consequently, it improves shoulder function and relieves pain. Purpose: To evaluate the rates of return to sports and physical work among patients treated with arthroscopic SCR.

Tears of the rotator cuff tendons can occur that do not allow anatomic footprint restoration yet may not be large enough to require a superior capsular reconstruction technique. Typically, these intermediate-sized tears are addressed with a medialized repair or partial repair technique. A partially repaired rotator cuff tendon, however, can lead to a high retear rate, as the repaired tendon is required to serve as both a dynamic tendon and a static ligamentous stabilizer. One potential static support, as a nearby autologous graft donor, is the proximal long head biceps tendon. The purpose of this Technical Note is to describe a surgical technique for an anterior cable reconstruction using the proximal biceps tendon for large rotator cuff defects.

; so, subjective scores were compared to pre-operative and 2 year post-operative scores from a similarly matched patient cohort [19]. These same dependent variables were used in a series of linear regressions to investigate their contribution in predicting failure of rotator cuff repair. Results: Investigators confirmed the eligibility of 301patients from a computer database. Eighty-one (27%) lacked current contact information, and 42 (14%) were deceased. Ninety-five (32%) for whom contact information was presumed to be current could not be reached. As a result, the number of non-responders versus those for whom contact information was no longer current could not be determined. Ultimately, contact was made with 83 of the 301 (28%) patients who underwent rotator cuff surgery between 1991 and 2003, four of whom declined to participate. Seventy-nine consented to the study and were included in the analysis, 65 male and 24 female. Mean (SD) age of participants at initial surgery was 55.7 (8) years. Initial tear size was identified for 63 participants, 7.9% (7) small, 38.1% (24) medium, 31.7% (20) large, and 22.2% (12) massive. Followup took place a mean 12.5 (3.5) years after the initial surgery, and mean age at follow-up was 68.2 (8.9) years. Mean (SD) age at the time of initial surgery was 55.7 (8.8) years. Mean (SD) WORC and ASES scores were 69.3% (22.7) and 72.0% (21.6), respectively. Nine had a positive Neer sign and 11% had positive Hawkin's sign for impingement. There were no significant differences between groups based on the patient characteristics outlined above. Mean WORC at follow-up of 69.3 (22.7)% compared favourably to pre-operative WORC of 35.6 (18.5)% for a similarly matched patient cohort at p < 0.05[19]. However, mean WORC at long-term follow-up was lower than at 2 years in the same matched cohort, 83.9 (18.9)% at p < 0.05[19]. Mean long-term ASES score was 72.9 (21.6)% and was significantly greater than the pre-operative ASES score of 44.6 (19.6)% for the matched cohort [19]. However, the long-term ASES scores were significantly lower than at 2 year post-surgery in the same matched cohort, 72.9 (21.6) compared to 88.0 (16.6) [19]. In the operated shoulder, fiftyeight percent of surpraspinatus muscles remained intact, 24 were partially re-torn, and 18% were fully re-torn, compared to the opposite side in which 77% were intact, 19% were partial tears, and 4% were fully torn on ultrasound. The difference between the two limbs was significantly different (p¼0.033). In total, nine patients (11%) subsequently underwent revision surgery for re-tear at an average of 8.6 years post-operative. A significant predictor of current supraspinatus status in the operated limb was age at the time of follow-up (p¼0.029; r 2 ¼0.104). Adding initial tear size to the model increased the strength of prediction (p¼0.017; r 2 ¼0.166), and smoking status increased the strength of prediction further (p¼0.015; r 2 ¼0.201). Gender, WCB status, and BMI were not significant predictors of supraspinatus status. In summary, older patients, greater initial tear size, and smokers at the time of surgery were significantly associated with re-torn supraspinatus at the time of follow-up. Current status of the repaired supraspinatus was a significant, but weak predictor of both WORC (p¼0.044; r2¼0.059) and ASES (p¼0.037; r2¼0.065). Supraspinatus status of the nonoperated side, age at the time of surgery or time of follow-up, gender, WCB status, smoking status, and BMI were not found to be predictive. Conclusions: Patients having undergone rotator cuff repair between 9 and 19 years ago are experiencing improved quality of lie from pre-surgery, but lower quality of life than 2-years post-surgery. In summary, this long-term retrospective case series demonstrates that patients who underwent rotator cuff repair between nine and twenty two years ago are experiencing improved function and quality of life when compared to pre-operative levels. Based on our results, patients that undergo rotator cuff repair can be counselled that improved function and quality of life can be expected well beyond 10 years from the time of surgery.

Purpose: To assess an anterior cable reconstruction (ACR) using autologous proximal biceps tendon for large to massive rotator cuff tears. Methods: Nine cadaveric shoulders (mean age, 58 years) were tested with a custom testing system. Range of motion, superior translation of the humeral head, and subacromial contact pressure were measured at 0 , 30 , 60 , and 90 of external rotation (ER) with 0 , 20 , and 40 of glenohumeral abduction. Five conditions were tested: intact, stage II tear (supraspinatus), stage II tear þ ACR, stage III tear (supraspinatus þ anterior half of infraspinatus), and stage III tear þ ACR. ACR involved a biceps tendon tenotomy at the transverse humeral ligament, preserving its labral attachment. ACR included nonpenetrating suture-loop fixation using 2 side-to-side sutures and an anchor at the articular margin to restore anatomy and secure the tendon along the anterior edge of the cuff defect. ACR was performed in 20 glenohumeral abduction and 60 ER. Results: ACR for both stage II and stage III showed significantly higher total range of motion compared with intact at all angles (P .001). ACR significantly decreased superior translation for stage II tears at 0 , 30 , and 60 ER for both 0 and 20 abduction (P .01) and for stage III tears at 0 and 30 ER for both 0 and 20 abduction (P .004). ACR for stage III tear significantly reduced peak subacromial contact pressure at 30 and 60 ER with 0 and 40 abduction and at 30 ER with 20 abduction (P .041). Conclusions: ACR using autologous biceps tendon biomechanically normalized superior migration and subacromial contact pressure, without limiting range of motion. Clinical Relevance: ACR may improve rotator cuff tendon repair longevity by providing basic static ligamentous support to the dynamic tendon while helping to limit superior migration without restricting glenohumeral kinematics.

Hypothesis: In a cadaveric irreparable rotator cuff tear model, patellar tendon allograft-superior capsule reconstruction (PT-SCR) will restore glenohumeral stability and reduce subacromial contact pressures without significant graft deformation during testing. Methods: Eight cadaveric shoulders were tested in a custom shoulder testing system. Rotational range of motion (ROM), superior translation, and subacromial contact pressure were measured in the following experimental conditions: intact rotator cuff, irreparable supraspinatus tear (massive cuff tear [MCT]), and PT-SCR. Results: MCT and PT-SCR resulted in significantly increased total ROM at all degrees of abduction compared with the intact state (P < .001). In both 0 and 30 of glenohumeral abduction, MCT showed a significant increase in superior translation compared with the intact state (P < .001). Application of the PT-SCR resulted in a decrease of superior translation compared with MCT (P < .001). At 0 abduction/60 external rotation and 0 abduction/90 external rotation, MCT showed significantly greater peak subacromial contact pressure compared with the intact state (P < .006). At both of these positions, PT-SCR was able to reduce peak pressure to lower than or no significant difference from the intact state. There was no statistically significant change in graft thickness, length, or width after testing. Conclusion: PT-SCR was able to reduce superior translation of the humeral head and peak subacromial contact pressure without restricting ROM. Furthermore, there was no significant graft deformation during testing. PT-SCR in this validated cadaveric model demonstrates favorable biomechanical properties and is a viable source of graft material for SCR. Institutional Review Board approval was not required for this basic science study. Investigation performed at

the double-row group, retears were found in 3 double tendon repairs. All 3 tears failed near the musculotendinous junction (Cho type 2). All clinical outcome measures were significantly improved from the preoperative level (p<0.0001), but there was no statistical difference between groups postoperatively Conclusion: There is no MRI difference in 12 month rotator cuff retear rates between triple-loaded single-row repairs or suture-bridging double-row repairs. Double-row repairs failed at the musculotendinous junction while single-row repairs failed at the reattachment site. No difference could be demonstrated between in clinical outcome scores either.

Purpose: To compare the biomechanical effectiveness of human dermal allograft (HDA) anterior capsular reconstruction (ACR) and pectoralis major tendon transfer (PMTT) for treating irreparable subscapularis tears with capsular insufficiency in human cadaver shoulders. Methods: Glenohumeral rotational range of motion and translation were measured in 6 cadaveric shoulders under the following 5 conditions: intact, deficient subscapularis/anterior capsule, ACR using HDA, HDA ACR with concomitant PMTT, and PMTT alone. Results: The deficient subscapularis/anterior capsule condition significantly increased external and total rotational range of motion at 0 (P < .001, P < .001) and 30 (P ¼ .005, P ¼ .002) abduction as well as anterior-inferior translation (P .001 to .03). HDA ACR, both with and without PMTT, restored anterior-inferior stability to that of the intact condition; however, PMTT alone did not restore anterior-inferior translation or rotational range of motion. Conclusions: HDA ACR for treating irreparable subscapularis tears with capsular insufficiency restored anterior-inferior glenohumeral translation and rotational range of motion at time 0 in human cadaver shoulders. Clinical Relevance: Anterior capsule reconstruction may be a viable option for treating massive irreparable subscapularis tears with capsular insufficiency.

Shoulder muscles contribute to both mobility and stability of the glenohumeral joint. To improve treatments for shoulder instability, we focused on the contribution of the shoulder muscles to glenohumeral joint stability in clinically relevant positions. Both computational and experimental models were used. A computational model of the glenohumeral joint quantified stability provided by active muscle forces in both mid-range and end-range glenohumeral joint positions. Compared with mid-range positions, the resultant joint force at end-range positions was more anteriorly directed, indicating that its contribution to glenohumeral joint stability was diminished. In end-range positions, simulated increases in rotator cuff muscle forces tended to improve stability whereas increases in deltoid or pectoralis major muscle forces tended to further decrease stability. To validate these results, a cadaveric model, simulating relevant shoulder muscles, was used to quantify glenohumeral joint stability. When infraspinatus muscle activity was decreased, compressive forces decreased. When pectoralis major muscle activity was increased, anteriorly directed forces increased. If anteriorly directed forces increase or compressive forces decrease, stability of the glenohumeral joint decreases. This cadaveric model was then used to evaluate the effect of placing the joint in the apprehension position of abduction, external rotation, and horizontal abduction. Consistent with the results of our computational model, apprehension positioning increased anteriorly directed forces. Knowledge gained from these models was then used to develop a cadaveric model of glenohumeral joint dislocation. Dislocation resulted from the mechanism of forcible apprehension positioning when the appropriate shoulder muscles were simulated and a passive pectoralis major muscle was included. Capsulolabral lesions resulted that were similar to those observed in vivo. Shoulder muscle forces are usually powerful stabilizers of the glenohumeral joint, especially in mid-range positions when the passive stabilizers are lax. However, muscle forces can contribute to instability as well. Certain muscle forces decrease glenohumeral joint stability in end-range positions. We found this to be the case with both active and passive pectoralis major forces. Improved understanding of the contribution of muscle forces not only toward stability but also toward instability will improve rehabilitation protocols for the shoulder and prove useful in the treatment of joint instability throughout the body.

formed part of the study. They were randomly allocated to one of the 2 treatment groups. Group 1 comprised of 33 patients who underwent MUA with steroid injection and Group 2 comprised of 45 patients who had Arthroscopic release. All procedures were performed by a single surgeon and results assessed by an independent observer unrelated to the study. The mean preoperative Oxford Shoulder score was 22.8 (SD 9.0) for group 1 and 24.2 (SD 7.3) for group 2 (p¼0.5). The mean preoperative DASH score was 48.9 (SD 16.6) for group 1 and 48.9 (SD 16.4) for group 2 (p¼0.9). The mean follow-up period was 14.6 months. On analysis of results, the mean range of motion of both groups improved flexion 170 AE 7, abduction 172 AE 5, external rotation 77 AE 7, internal rotation T9 AE 1 (p<0.001). The mean Oxford score improved to 44.1 (SD 3.7) for group 1 and 40.9 (SD 7.8) for group 2. The mean DASH score improved to 9.8 (SD 9.8) for group 1 and 18.4 (SD 21.2) for group 2. The follow-up Oxford and DASH scores for group 1 were superior to group 2 (p¼0.03) and (p¼0.04) respectively. In conclusion, MUA with steroid injection and Arthroscopic release showed significant improvement in patient outcome. In addition, in our study, MUA with steroid injection gave statistically superior results in comparison to Arthroscopic release for Frozen shoulder.

To compare the outcomes of patients who undergo a long head of the biceps (LHB) procedure (tenotomy or tenodesis) concomitant with rotator cuff repair (RCR) to those of patients who undergo isolated RCR. Prospectively collected data were retrospectively reviewed on 80 patients, &gt;18 years old, who underwent repair of a full-thickness rotator cuff tear and with 1-year patient-reported outcome scores collected June 2012 to March 2015. The exclusion criteria were concomitant procedures other than LHB tenotomy, tenodesis, or subacromial decompression; prior shoulder surgery; or other shoulder pathology. The 3 patient groups are as follows: RCR + tenotomy, RCR + tenodesis, and isolated RCR. The primary outcome measures were American Shoulder and Elbow Surgeons (ASES) score, Western Ontario Rotator Cuff (WORC) index, and visual analog scale (VAS) for pain. A t-test measured the mean improvement in LHB patients compared with isolated RCR patients and compared the LHB tenotomy and tenodes...

Purpose: This study was designed to quantify tensile forces within the intra-articular long head of the bicep tendon (LHBT) under conditions of passive limb positioning and physiologic load, which simulate contraction of the LHBT. Materials and Methods: A force probe was inserted into the intra-articular LHBT, just distal to its supra-glenoid origin, in six fresh-frozen cadaveric specimens. Initially, specimens were manually manipulated through 30 glenohumeral joint positions, combining humeral rotation and elbow/forearm position. In the second phase, a 55 N tensile load was applied through the LHBT in 18 limb positions. Intra-tendinous tension was recorded in all positions under both conditions. Results: External humeral rotation significantly increased tension with glenohumeral forward flexion (P<0.0001). Conversely, internal humeral rotation significantly increased tension with glenohumeral abduction and extension (P<0.0001). A position of glenohumeral extension and internal rotation, with the elbow extended and forearm pronated, produced the highest tension in the intra-articular LHBT (P<0.0001). Under applied load conditions, observed LHTB tension was not statistically different in any glenohumeral position (P=0.1468, power = 88%). The greater tuberosity was noted to impinge on the force probe in forward flexion and internal rotation in two specimens. Conclusions: Variable tensile forces are seen in the intra-articular LHBT as a function of both limb position and simulated biceps contraction. Our findings provide a thorough data set that may be used to help substantiate or refute current or future hypotheses regarding LHBT function, pathology, and clinical tests. Clinical Relevance: Identifying positions of glenohumeral motion, which affect LHBT tension will provide an anatomic basis for clinical tests proposed to be for diagnosing LHBT lesions, including superior labral anterior and posterior tears.

Purpose: This study was designed to quantify tensile forces within the intra-articular long head of the bicep tendon (LHBT) under conditions of passive limb positioning and physiologic load, which simulate contraction of the LHBT. Materials and Methods: A force probe was inserted into the intra-articular LHBT, just distal to its supra-glenoid origin, in six fresh-frozen cadaveric specimens. Initially, specimens were manually manipulated through 30 glenohumeral joint positions, combining humeral rotation and elbow/forearm position. In the second phase, a 55 N tensile load was applied through the LHBT in 18 limb positions. Intra-tendinous tension was recorded in all positions under both conditions. Results: External humeral rotation significantly increased tension with glenohumeral forward flexion (P<0.0001). Conversely, internal humeral rotation significantly increased tension with glenohumeral abduction and extension (P<0.0001). A position of glenohumeral extension and internal rotation, with the elbow extended and forearm pronated, produced the highest tension in the intra-articular LHBT (P<0.0001). Under applied load conditions, observed LHTB tension was not statistically different in any glenohumeral position (P=0.1468, power = 88%). The greater tuberosity was noted to impinge on the force probe in forward flexion and internal rotation in two specimens. Conclusions: Variable tensile forces are seen in the intra-articular LHBT as a function of both limb position and simulated biceps contraction. Our findings provide a thorough data set that may be used to help substantiate or refute current or future hypotheses regarding LHBT function, pathology, and clinical tests. Clinical Relevance: Identifying positions of glenohumeral motion, which affect LHBT tension will provide an anatomic basis for clinical tests proposed to be for diagnosing LHBT lesions, including superior labral anterior and posterior tears.

Background Patients undergoing arthroscopic shoulder surgery in the beach chair position may be at increased risk for serious neurocognitive complications as a result of cerebral ischemia. Questions/purposes We sought to define the (1) incidence; (2) timing; and (3) magnitude of intraoperative cerebral desaturation events (CDEs) in subjects undergoing arthroscopic shoulder surgery in the beach chair position, as well as whether (4) the length of surgery was an independent risk factor for intraoperative CDEs. Methods Regional cerebral tissue oxygen saturation (rSO 2) was monitored intraoperatively using near-infrared spectroscopy on 51 consecutive patients undergoing arthroscopic shoulder surgery in the beach chair position. Intraoperative decreases in rSO 2 of 20% or greater were defined as CDEs. Results The incidence of intraoperative CDEs in our series was 18% (nine of 51). Among the patients demonstrating CDE (n = 9), the mean time to onset of initial CDE was 18 minutes 38 seconds postinduction. Of those experiencing CDEs, the mean maximal decrease in rSO 2 was 32% from preoperative baseline per patient. Additionally, the mean number of separate CDE instances was 1.89 in this patient population with an average duration of 3 minutes 3 seconds per instance. There was no statistically significant difference (p = 0.202) between patients demonstrating CDEs and those without in regard to length of surgery (95 versus 88 minutes). Conclusions The degree and duration of cerebral ischemia required to produce neurocognitive dysfunction in this patient population remains undefined; however, cerebral oximetry with near-infrared spectroscopy allows prompt identification and treatment of decreased cerebral perfusion. We believe protocols aimed at detecting and reversing CDE may improve patient safety. Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

While the biceps muscle tendon shows the highest rate of rupture of all tendons, this lesion is very infrequent in the tendon of the pectoralis major. According to Pulaski & Chandler (1941), the first case was published in 1822 by Patassier. In this, septic infection developed

Objective: This prospective, randomized study aimed to compare anterior suprascapular nerve block versus interscalene block in terms of diaphragm paralysis in arthroscopic shoulder surgery. Methods: Fifty-two patients undergoing shoulder arthroscopy surgery were prospectively randomly assigned to interscalene block (n = 25) or anterior suprascapular nerve block groups (n = 27) (each group receiving 5 mL, 0.5% bupivacaine). The ipsilateral diaphragmatic excursion was assessed in all patients using ultrasound imaging before (baseline), 30 minutes, and 24 hours after block completion. Pain scores were recorded 1 hour preoperative, 30-60 minutes in the postoperative recovery unit, and at 6 and 24 hours postoperatively. Results: No complete paralysis was observed in either treatment group. The incidence of a partial decrease in diaphragm movements was significantly lower in the anterior suprascapular nerve block than in the interscalene block group (1 vs. 21 patients) (P < .01). Twenty-six patients in the anterior suprascapular nerve block and 4 in the interscalene block group had less than a 25% decrease in hemidiaphragmatic movements, 30 minutes after the blockade. Pain scores were similar in the 2 groups. However, mean pain scores at 24 hours postoperatively were significantly higher in the interscalene block than in the anterior suprascapular nerve block group (P < .05). Time to first pain post-block was significantly longer in the anterior suprascapular nerve block compared to the interscalene block group (677.04 ± 52.17 minutes vs. 479.2 ± 99.74 minutes, P < .05). Conclusion: Anterior suprascapular nerve block and interscalene block both appear to be clinically effective in providing postoperative analgesia for patients undergoing arthroscopic shoulder surgery under general anesthesia. However, the time to first pain is significantly longer with anterior suprascapular nerve block. Pain scores at 24 hours postoperatively were significantly lower in the anterior suprascapular nerve block compared to the interscalene block group. Diaphragmatic movements after anterior suprascapular nerve block were also better preserved at both 30 minutes after the block and 24 hours after surgery.

Background: Biomechanical and clinical success of the superior capsule reconstruction (SCR) using fascia lata (FL) grafts has been reported. In the United States, human dermal (HD) allograft has been used successfully for SCRs; however, the biomechanical characteristics have not been reported. Methods: Eight cadaveric shoulders were tested in 5 conditions: (1) intact; (2) irreparable supraspinatus tear; (3) SCR using FL allograft with anterior and posterior suturing; (4) SCR using HD allograft with anterior and posterior suturing; and (5) SCR using HD allograft with posterior suturing. Rotational range of motion, superior translation, glenohumeral joint force, and subacromial contact were measured at 0°, 30°, and 60°of glenohumeral abduction in the scapular plane. Graft dimensions before and after testing were also recorded. Biomechanical parameters were compared using a repeated-measures analysis of variance with Tukey post hoc test, and graft dimensions were compared using a Student t-test (P < .05). Results: Irreparable supraspinatus tear significantly increased superior translation, superior glenohumeral joint force, and subacromial contact pressure, which were completely restored with the SCR FL allografts. Both SCR HD allograft repairs partially restored superior translation and completely restored subacromial contact and superior glenohumeral joint force. The HD allografts significantly elongated by 15% during testing, whereas the FL allograft lengths were unchanged.

A test-retest design was used to evaluate the reliability of the self-report sections of 4 shoulder pain and disability scales. Objective: The objective of the study was to compare interitem consistency and test-retest reliability by surgical status (postoperative versus nonoperative) and to evaluate the effect of surgical status in the prediction of retest scores. Background: Patients and healthcare providers evaluate shoulder status based on self-evaluations of pain and disability. Shoulder outcome measures have been developed that include self-reports, but the properties of these measures have not been assessed by surgical status. Methods and Measures: A questionnaire containing self-report sections of 4 shoulder scales was administered to study participants twice with 1 week between administrations. The outcome measures examined were the: (1) University of California at Los Angeles (UCLA) Shoulder Score; (2) Constant-Murley Scale (CMS); (3) American Shoulder and Elbow Society (ASES) Shoulder Index; and (4) Shoulder Pain and Disability Index (SPADI). Intraclass correlation coefficients (ICC) were calculated to estimate the test-retest reliability of each of the scales and subscales. The interitem consistencies of the multi-item subscales were assessed using Cronbach's alpha. The effect of surgical status on shoulder outcome scale reliability was evaluated using a general linear models approach. Results: The interitem consistency estimates for the multi-item scales were high with both operative and nonoperative participants (0.88 to 0.96). With the exception of the satisfaction subscale of the UCLA Shoulder Score for the nonsurgical group, the estimated intraclass coefficients ranged from 0.51 to 0.91. The prediction of UCLA-satisfaction and ASES-disability, pain, and total retest scores was improved with the addition of surgical status into a regression model.

All-arthroscopic anchorless transosseous suture techniques combine the advantages of the open transosseous repair with the benefits of arthroscopic technique. However, all the techniques described until now are very complex, difficult to reproduce and associated with an increased surgical time. The authors developed a novel allarthroscopic anchorless transosseous suture technique easy to perform and to reproduce. This procedure maximizes the tendon-footprint contact area obtaining both medial and lateral fixation without using any device, employing only 1 suture tape so to avoiding the risk of suture twist. The preparation of two transosseous tunnels is very easily and safely performed thanks to a dedicated instrument. The procedure is described in details. Moreover, the preliminary favorable results after a minimum follow-up of 12 months are reported.

Background: Mechanical factors are at the basis of any tendon healing process, being pressure an aspect able to positively influence it. For this reason transosseous rotator cuff repair represents the gold standard procedure for patients affected by a cuff tear, maximizing the tendon footprint contact area and reducing motion at the tendon to bone interface. Methods: The Authors present an all arthroscopic suture bridge-like transosseous repair with the preparation of a single transosseous tunnel perfor med thanks to a precise dedicated instrument (Compas-so®) and one implant (Elite-SPK®) with the use of only 3 suture wires. In addition this technique permits to accurately prepare the bony side of the lesion without any risk or complication, such as anchor pull-out and greater tuberosity bone osteolysis. Conclusions: However, even if this technique seems less demanding, the arthroscopic transosseous repair is still an advanced procedure, and should be performed only by well prepared arthroscopic shoulder surgeons. Level of evidence: V.

Purpose: To evaluate the prevalence of Cutibacterium acnes in the shoulder region and to analyze changes in C acnes contamination during shoulder arthroscopy, as well as to investigate the influence of sex and type of arthroscopic surgery on those parameters. Methods: Forty-eight consecutive patients undergoing reconstructive or non-reconstructive shoulder arthroscopy, after hair removal with a medical clipper, routine antibiotic prophylaxis, and skin preparation with an alcohol-based skin disinfectant, were prospectively enrolled in this study. The shoulder was divided into 4 regions of interest (anterior, medial, posterior, and axilla). Skin swabs were taken from each region at 3 time points (preoperatively before and after skin preparation, and at the conclusion of surgery), cultured for 21 days, and analyzed for the prevalence of C acnes. Results: The rate of C acnesepositive skin cultures was significantly increased at the end of surgery compared with preoperatively before (44.3% vs 27.6%, P < .001) and after (44.3% vs 31.3%, P ¼ .001) skin preparation. No reduction in C acnes was observed with preoperative skin preparation (27.6% vs 31.3%, P ¼ .401). At the end of shoulder arthroscopy, 64.6% of patients showed at least 1 culture positive for C acnes. The C acnes prevalence was significantly higher in male patients (48.3%) than female patients (20.1%, P < .001), at all time points (P < .016), and in all regions of interest (P < .001) except the axilla. No differences in the prevalence of C acnes were found between non-reconstructive and reconstructive procedures. Conclusions: Skin contamination with C acnes around the shoulder increased significantly from before and after skin preparation to the conclusion of surgery in patients undergoing shoulder arthroscopy despite perioperative preventive measures. Level of Evidence: Level IV, therapeutic case series.

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Surgically repaired rotator cuff repairs may re-tear in the post-operative follow-up phase, and periodic imaging is useful for early detection. The authors describe a simple surgical technique that provides a visible clue to the tendon edge on an anteroposterior radiograph of the shoulder. The technique involves arthroscopic or mini-open radio-opaque tagging of the tendon edge using a metal marker, and followed by a double-row rotator cuff repair using suture anchors. Serial post-operative radiographs may then be used to monitor the position of the marker. Progressive or marked displacement of the marker suggests a failure of cuff repair integrity and should be evaluated further.

Sternoclavicular joint The Sternoclavicular (SC) joint is injured when the player falls directly onto the shoulder. The joint may be painfully swollen or frankly dislocated. Anterior subluxation of the joint is by far the most frequent; the more dangerous posterior subluxation is relatively rare.

Shoulder instability in the middle-aged and elderly patients: Pathology and surgical implications Shoulder instability is frequently encountered in young patients and commonly follows sporting injuries. There are well-recognized aspects pertaining to labral tears and bone loss leading to increased risks for re-dislocations and high recurrence rates in the young. However, shoulder instability in the middle-aged and elderly patients is an under-recognized problem, with a different pathological spectrum and specific surgical implications. [1,2] This article outlines the principles that guide management of this entity.

Ewing's sarcoma is a malignant non-osteogenic primary tumor of the bone. It is one of the most common primary malignant tumors of bone. Peak incidence is noticed in second decade of life with male preponderance of 1.6:1. It occurs most frequently in long bones and flat bones of pelvic girdles. In 30% cases, Ewing's sarcoma is multicentric in origin. In 14-50%, multiple metastases are present at the time of diagnosis. CNS spread is rare and isolated CNS involvement is not seen. Skull metastasis of Ewing's sarcoma is not rare compared to primary Ewing's sarcoma of the skull, but the actual frequency is unknown. We wish to report a case of "Primary Ewing's sarcoma of scapula with metastasis to Skull Vault in a Child resulting in sutural diastasis" diagnosed by clinicoradiological examination and confirmed by histopathology.