The Journal of Bone and Joint Surgery (American). 2006;88:230-243.
doi:10.2106/JBJS.E.01165
© 2006 The Journal of Bone and Joint Surgery, Inc.
What's New in Shoulder and Elbow Surgery
Gary M. Gartsman, MD1 and
Samer S. Hasan, MD, PhD2
1 Texas Orthopedic Hospital, Fondren Orthopedic Group, 7401 South Main Street,
Houston, TX 77030. E-mail address:
gmg{at}fondren.com
2 Cincinnati Sportsmedicine and Orthopaedic Center, 12115 Sheraton Lane,
Cincinnati, OH 45246
Specialty Update has been developed in collaboration with the Council of
Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
The authors did not receive grants or outside funding in support of their
research for or preparation of this manuscript. They did not receive payments
or other benefits or a commitment or agreement to provide such benefits from a
commercial entity. No commercial entity paid or directed, or agreed to pay or
direct, any benefits to any research fund, foundation, educational
institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
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Sources
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The sources for this annual update on shoulder and elbow surgery were
presentations and symposia at meetings of The American Orthopaedic Society for
Sports Medicine (Specialty Day, February 26, 2005, Washington, DC), the
Arthroscopy Association of North America (Specialty Day, February 26, 2005,
Washington, DC; Twenty-fourth Annual Meeting, May 12-15, 2005, Vancouver,
British Columbia, Canada; and Twenty-third Fall Course, December 2-4, 2004,
Palm Desert, California), the American Academy of Orthopaedic Surgeons
(Seventy-second Annual Meeting, February 23-27, 2005, Washington, DC), the
Orthopaedic Research Society (Fifty-first Annual Meeting, February 20-23,
2005, Washington, DC), the American Shoulder and Elbow Surgeons (Twenty-first
Open Meeting, Specialty Day, February 26, 2005, Washington, DC; and
Twenty-first Annual Meeting, September 29-October 2, 2004, New York, NY) and
the American Orthopaedic Association (118th Annual Meeting, June 22-25, 2005,
Huntington Beach, California).
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Shoulder
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Rotator Cuff
Basic Science
Yokota reported on changes in supraspinatus tendon composition following
tendon detachment and retraction in a rat model. At various time-points
following tendon detachment, the rats were killed and the supraspinatus
tendons were studied histologically. Disorganized scar tissue was present
between the insertion and the tendon stump, but tendon composition changed
with time after detachment, suggesting that the quality of an acute tear
differs from that of a chronic tear. Dines provided an interim report on
tissue-engineering and gene-therapy interventions to enhance rotator cuff
healing in a rat model. Rat tendon fibroblasts were transduced with genes for
platelet-derived growth factor-beta with use of retroviral vectors and were
seeded onto a polymer scaffold and further cultured. Supraspinatus tendon
tears were created in rats, which were randomized into three groups (control,
repair, and repair with a gene-modified tendon tissue construct).
Analysis of tissue harvested at six weeks following repair revealed that
normal tendon architecture was reliably restored in the experimental repair
group alone. Histological analysis demonstrated a normal crimp pattern and
collagen bundle alignment. The study demonstrated the efficacy of biologically
active implants for rotator cuff repair in a rat model that closely replicated
the clinical sequence of tear, inflammation, and repair. Cole tested the
hypothesis that bipolar radiofrequency energy enhances the repair of chronic
supraspinatus tendon tears in a rat model. At twelve weeks, tendons that had
had bipolar radiofrequency energy treatment withstood significantly greater
maximum stress than those that had not (p < 0.05), and, at eight weeks,
repaired tendons and controls had an identical histological appearance. He
concluded that adjunctive bipolar radiofrequency energy appears to enhance the
biomechanical and histological properties of tendon repair. Frostick examined
the relationship between vascular proliferation and nonsteroidal
anti-inflammatory drugs in a study of patients with a torn rotator cuff.
Rotator cuff tissue was obtained from fifty-three patients undergoing repair.
Vascular proliferation was absent or reduced in twenty-two of thirty-five
patients who were taking analgesics. Twenty of these patients were taking
nonsteroidal anti-inflammatory drugs, and four were taking only
Cox-II-selective inhibitors. Eight of ten patients who were not taking
nonsteroidal anti-inflammatory drugs demonstrated active ongoing vascular
proliferation (p < 0.05). Because endothelial cell proliferation is an
important component of the rotator cuff repair process, one could conclude
that routine use of nonsteroidal anti-inflammatory drugs may compromise
rotator cuff healing and repair.
In an effort to improve tendon-to-bone healing, Mazzocca reported on a
novel suture material with a biologically active collagen coating. Human
osteoblasts and tenocytes were plated onto three types of suture, including
suture braided with type-I collagen. At forty-eight hours, the collagen-coated
suture had three times the osteoblast proliferation as compared with the
polyester/polyethylene suture and it had nearly eight times the osteoblast
proliferation as compared with the polyester suture. Greater protein synthesis
was measured on the collagen-coated suture. The study demonstrated that
collagen-coated suture may hold promise for augmenting tendon-to-bone
incorporation during rotator cuff repair.
Meier presented the results of a study of the effect of double-row fixation
on initial rotator cuff repair strength. Rotator cuff tears were created in
twenty-one cadaveric shoulders and then were repaired with use of one of three
different techniques involving the use of transosseous sutures, single-row
suture anchors, or double-row suture anchors. Specimens were cyclically loaded
for 5000 cycles or until a 10-mm gap formed. The double-row suture-anchor
technique was significantly stronger than the single-row suture-anchor
technique (p < 0.001), and both were significantly stronger than the
transosseous suture technique (p < 0.001). Other studies of rotator cuff
fixation led to different conclusions. Costic studied simulated rotator cuff
repairs in cadaveric shoulders. Biomechanical properties and footprint contact
area were measured following single-row and double-row repair. In contrast to
other recent studies, double-row repair did not demonstrate superior initial
biomechanical properties. However, the increased contact area suggested the
potential for better tendon-to-bone healing. Jazrawi evaluated the effect of
arthroscopic suture-passing instruments on the integrity of rotator cuff
repair in a study of eight cadaveric shoulders. Overall, the study
demonstrated considerable differences in the number of cycles to failure,
depending on the instrument used for suture passage. Suture-passing
instruments with smaller and smoother tips create more symmetric holes in
tendon and may prevent suture cutout.
Impingement
Browdy reported on the association between glenohumeral internal rotation
deficit and labral pathology. Three hundred and eight professional baseball
players underwent measurement of bilateral shoulder rotation in abduction,
including 264 players who remained injury-free during a five-year study
period, thirty players who had a history of a labral injury at the time of
measurement, and fourteen players who subsequently had development of a labral
injury. With the numbers available, there were no significant differences
between the three groups, suggesting that glenohumeral internal rotation
deficit caused by acquired posterior capsular contracture does not predispose
to labral pathology in the overhead athlete. Myers evaluated posterior
capsular contracture and glenohumeral internal rotation deficit with use of
gadolinium-enhanced magnetic resonance imaging in a study of eleven throwing
athletes with internal impingement and eleven matched control throwers without
injury. Passive glenohumeral internal rotation and external rotation were
measured bilaterally. Posterior capsular contracture was defined as the
bilateral difference in shoulder horizontal adduction with the scapula
retracted and the shoulder elevated 90°. Throwing athletes with internal
impingement demonstrated significantly greater glenohumeral internal rotation
deficit (p < 0.05) and posterior capsular contracture (p < 0.05) than
control subjects did. No accompanying increase in external rotation was noted.
In contrast to the study summarized above, the authors believed that posterior
capsular contracture may contribute to internal impingement of the posterior
part of the rotator cuff and the posterosuperior aspect of the labrum by
shifting the glenohumeral contact point posterosuperiorly during throwing.
DeBritz presented the results of a randomized, placebo-controlled,
double-blind study that was performed to evaluate extracorporeal shock wave
therapy for the treatment of impingement syndrome. Although the effectiveness
of extracorporeal shock wave treatment has been documented for certain overuse
conditions such as lateral epicondylitis, no benefit was demonstrated in this
study of patients with recalcitrant impingement syndrome. Van Riet reported on
the increase in paratracheal pressure during arthroscopic subacromial
decompression. Forty patients undergoing arthroscopic decompression were
managed with 21-gauge needles that were placed into the deltoid and
supraspinatus muscles and into the paratracheal region. Although in most
patients the average paratracheal pressure was 1 mm Hg throughout the
procedure, four patients experienced a sharp and unpredictable increase in
paratracheal pressure to a maximum of 133 mm Hg. The increase in paratracheal
pressure that was observed in these four patients could be potentially
life-threatening, suggesting that endotracheal intubation is mandatory for
patients undergoing arthroscopic subacromial surgery.
Partial-Thickness Tears
Weber evaluated the accuracy of magnetic resonance imaging in the diagnosis
of partial-thickness rotator cuff tears. Eighty consecutive magnetic resonance
imaging scans that were interpreted by the radiologist as showing either a
"partial rotator cuff tear" or a "possible partial rotator
cuff tear" were identified over a twelve-month period. All patients
underwent physical examination, a lidocaine impingement test, and diagnostic
arthroscopy. The correlation between magnetic resonance imaging findings and
arthroscopic findings was poor. At the time of arthroscopy, thirty-eight
patients had no tear and twenty-five patients had a complete tear. The
true-positive rate was 22% and the false-positive rate was 78%, so that,
overall, only seventeen of eighty patients were diagnosed correctly. In
contrast, seventy patients were diagnosed correctly with use of Neer's
criteria on the basis of a combination of physical examination findings and a
positive lidocaine impingement test.
Kim reported on the results of arthroscopic treatment of articular-sided
partial-thickness rotator cuff tears in 109 shoulders after a mean duration of
follow-up of forty-nine months. Low-grade tears underwent débridement,
whereas high-grade (Ellman grade-III) tears underwent conversion to a
full-thickness tear followed by arthroscopic repair. Each patient was
classified as a throwing athlete, a nonthrowing athlete, or a nonathletic
patient. Throwing athletes demonstrated a higher prevalence of unsatisfactory
results. The study underscored that arthroscopic débridement alone is
inadequate for the treatment of the throwing athlete. Following repair, the
likelihood of return to full activity is lower in this high-demand
population.
Full-Thickness Tears
Baumgarten demonstrated that smoking increases the risk of rotator cuff
tears. Multiple other demographic factors, including manual labor, exercise
habits, prednisone use, and diabetes, were not correlated with an increased
risk of rotator cuff tears. These findings are important considerations in the
evaluation and counseling of patients with shoulder pain. Ziegler used
diagnostic ultrasound to compare shoulder elevation in intact and rotator
cuff-deficient shoulders. In athletes, the tuberosity smoothly cleared under
the acromion during active elevation at a mean elevation of 65°,
suggesting that overhead shoulder dysfunction does not result from pathologic
contact between the acromion and the underlying rotator cuff. Gartsman, in a
study of 190 patients (192 shoulders) with a mean age of sixty-seven years who
had a full-thickness rotator cuff tear, reported on the correlation between
pain and functional outcome following nonoperative treatment involving pain
management and a home exercise program. After a mean duration of follow-up of
3.3 years, the mean American Shoulder and Elbow Surgeons (ASES) score was 70
for the involved shoulder, compared with 87 for the uninvolved shoulder.
Evidence of muscle atrophy on magnetic resonance imaging was associated with
significantly worse ASES scores for pain (p < 0.05) and activities of daily
living (p < 0.001), but tendon retraction, multiple tendon involvement,
dominant arm involvement, gender, age, and duration of follow-up were not
correlated with the ASES scores. The reported scores were higher than
previously reported preoperative scores but were considerably lower than
scores reported following rotator cuff repair. Zingg reported on the clinical
and structural results following the nonoperative treatment of massive rotator
cuff tears. Nineteen patients with a massive rotator cuff tear involving at
least two complete tendons (as demonstrated with magnetic resonance imaging)
who had not undergone an operation (because of modest symptoms and functional
demands) were evaluated clinically, radiographically, and with magnetic
resonance imaging after a mean duration of follow-up of forty-eight months.
During the follow-up period, acromiohumeral distance decreased significantly
(p < 0.005), indicating superior migration of the humeral head, and rotator
cuff tear size increased significantly (p < 0.005). Fatty muscle
degeneration increased significantly, by an average of one grade (p <
0.001). Glenohumeral arthritis progressed significantly (p < 0.05) and was
most pronounced in patients with three-tendon tears (p < 0.05). Four of
eight rotator cuff tears that initially had been classified as reparable
became irreparable during the study period. The authors concluded that massive
tears that are treated nonoperatively can maintain relatively good clinical
and functional results but that structural changes progress so that one-half
of all reparable massive rotator cuff tears become irreparable within four
years. Isbell tested the hypothesis that patients with asymptomatic combined
supraspinatus and infraspinatus tears have greater subscapularis activity
during everyday activity than those with symptomatic tears do. During tasks
involving shoulder elevation, symptomatic patients had greater upper trapezius
muscle activation than asymptomatic patients did. During forward elevation
with an 8-lb (3.6-kg) weight, asymptomatic patients demonstrated greater
subscapularis and deltoid activity than symptomatic patients did. Increased
activity of the torn rotator cuff and periscapular muscles may compromise
function and influence symptoms.
Stetson summarized the results of a prospective, randomized, double-blind
study of forty-seven patients that evaluated the use of a pain-control
infusion pump following arthroscopic rotator cuff repair. A standard epidural
catheter was placed arthroscopically into the subacromial space following
surgery in order to allow for a slow infusion of either normal saline solution
or 0.25% bupivacaine with epinephrine. Postoperative pain levels and narcotic
requirements were measured with use of a visual analog scale. The study
demonstrated that patients in the experimental group experienced less pain on
the day of surgery and on the first two postoperative days. Patients in the
experimental group also used 25% less narcotics than those in the control
group did.
Matsen presented the two to ten-year results of open rotator cuff repair
without acromioplasty. At the time of follow-up, the proportion of patients
who were able to perform each of the twelve functions on the Simple Shoulder
Test (SST) improved significantly (p < 0.001). The physical role function
and comfort domains of the Short Form-36 (SF-36) improved significantly as
well (p < 0.001). The study demonstrated good results following rotator
cuff repair with use of a technique that did not involve acromioplasty,
similar to that employed by Codman seventy years earlier.
Green found that preoperative patient expectations predicted the outcome of
rotator cuff repair. Self-assessment forms (including the SST; the
Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire; three visual
analog scales for shoulder pain, shoulder function, and quality of life; and
the SF-36) were completed both preoperatively and one year postoperatively by
125 patients undergoing repair of a chronic rotator cuff tear. Preoperative
expectations were quantified with use of a separate questionnaire. Greater
pre-operative expectations were correlated with better postoperative
performance on the SST, the DASH questionnaire, the visual analog scales, and
the SF-36 (range of p values, 0.0001 to 0.03) and with greater improvement on
the DASH and SF-36 (range of p values, 0.0001 to 0.02). The author noted that
variations in patient expectations may help to explain the variability in
outcome among different populations.
Subscapularis Tears
Kim reported on twenty-nine patients in whom an all-arthroscopic,
intra-articular repair was performed for the treatment of an isolated,
partial, articular-sided avulsion tear of the subscapularis. More than
one-half of the tears measured 1 cm in width. Suture anchors were employed,
and concomitant biceps tenodesis was performed in sixteen patients. After a
mean duration of follow-up of twenty-seven months, twenty-eight patients had a
good or excellent result according to the ASES score and internal rotation
strength deficits had decreased from 32% to 4%. The author noted that the
intra-articular technique preserved the intact bursal-side tendon attachment
but added that the duration of follow-up was short.
Massive and Irreparable Tears
Warner reported on suprascapular nerve dysfunction in association with
massive rotator cuff tears. In that study, four of seven patients who had a
chronic massive rotator cuff tear associated with substantial fatty muscle
atrophy and an isolated suprascapular nerve injury on electromyography
underwent either complete arthroscopic repair or partial arthroscopic repair
of the posterior portion of the rotator cuff. Postoperative electromyography
demonstrated recovery of suprascapular nerve function. The author proposed
that suprascapular nerve injury results from traction on the nerve when the
torn rotator cuff tendons retract and resolves following partial or complete
rotator cuff repair. Mullett reported on the role of anterior deltoid
re-education in patients with chronic massive irreparable rotator cuff tears.
Seventeen patients with an age of seventy years or more who had a painful
massive rotator cuff tear and resultant deficits in active shoulder elevation
were instructed in the use of a home exercise program. The patients were
instructed to perform deltoid muscle exercises in the supine position at least
three times daily for six weeks and to gradually incline the head of the bed
throughout the course of the exercise program. Ninety percent of the
participants reported improved upper extremity function following six weeks of
treatment.
Complications
Jost presented the long-term outcome after the failure of rotator cuff
repairs. Twenty patients with a mean age of fifty-nine years at the time of
repair were evaluated at a mean of 3.2 years and again at a mean of 7.6 years
following a repeat tear that was confirmed with use of magnetic resonance
imaging. With the numbers available, the mean size of the repeat tear did not
change significantly from 3.2 to 7.6 years. At the time of the latest
follow-up, seven patients had a repeat tear that was limited to the
supraspinatus and eight patients had a repeat tear that had apparently healed.
Fatty degeneration of the supraspinatus and subscapularis and the degree of
glenohumeral arthritis did not progress during the study period, but fatty
degeneration of the infraspinatus progressed significantly (p < 0.05) and
the acromiohumeral distance decreased significantly (p < 0.01). Nineteen
patients were either very satisfied or satisfied, and the relative Constant
score improved from 83% at 3.2 years to 88% at 7.6 years. The study
demonstrated that most repeat tears do not progress over time and that some
small repeat tears may heal. In addition, a good outcome is often possible
despite a repeat tear. Brislin reported on complications following
arthroscopic rotator cuff repair. Twenty-eight (11%) of 263 consecutive
patients who underwent arthroscopic rotator cuff repair during a six-month
period had development of a postoperative complication. Twenty-three patients
were diagnosed with postoperative stiffness that persisted for three months or
longer. The study demonstrated that arthroscopic rotator cuff repair does not
eliminate postoperative stiffness but that the overall complication rate
compares favorably with that following traditional open or mini-open
repair.
Biceps Tendon
Bernas compared bone tunnel, keyhole, subpectoral bone tunnel, suture
anchor, and bioabsorbable interference screw techniques for tenodesis of the
long head of the biceps. Forty frozen cadaveric specimens were randomized to
one of the five repair techniques. Completed repairs underwent destructive
testing to determine load to failure, mode of failure, elongation, and linear
stiffness. The bioabsorbable interference screw technique demonstrated the
highest load to failure of all of the repair techniques, but the native tendon
had a significantly higher load to failure (p < 0.05), suggesting that the
repair must be protected postoperatively.
Acromioclavicular Joint
Jensen reported on horizontal acromioclavicular joint instability following
chronic displaced acromioclavicular joint separations and failed distal
clavicular excisions. Surgical reconstruction involved coracoacromial ligament
transfer to the trapezoid insertion, posterior acromioclavicular joint
ligament reconstruction, and coracoclavicular internal fixation. Forty-one
patients were evaluated after a mean duration of follow-up of thirty-eight
months. None of the patients had a positive acromioclavicular pivot-shift test
(characterized by pain on anterior loading of the posterior aspect of the
acromion while the clavicle is stabilized), and all of the patients were
satisfied with the result of surgery. Krishnan reported on acromioclavicular
joint reconstruction with use of an autogenous semitendinosus graft for the
treatment of type-V separations. Nine consecutive patients underwent distal
clavicular excision, coracoacromial ligament transfer, coracoclavicular
reconstruction with use of suture, and semitendinosus grafting around the
coracoid process and through drill-holes in the clavicle coupled with superior
acromioclavicular joint capsule reconstruction with use of the remaining
graft. The author suggested that this technique limits posterior translation
of the clavicle during active motion.
Glenohumeral Instability
Basic Science
Jazrawi studied the effects of rotator interval closure on glenohumeral
motion and translation with use of a cadaveric model. The author recommended
the use of a single lateral suture for rotator interval closure because it
influenced translation similar to the use of two sutures but resulted in less
loss of external rotation. Closure with a single medial suture had the least
effect on reducing anterior translation and may decrease external rotation
excessively.
Shafer studied the effects of capsular plication and rotator interval
closure in a study of seven cadaveric shoulders that were nondestructively
stretched to simulate multidirectional instability. Capsular plication
sequentially reduced the range of motion to that of an uninjured shoulder. The
author found that rotator interval closure reduced anteroposterior translation
but also noted that it may result in loss of motion or over-tightening
compared with the uninjured shoulder. Vibert studied the effects of
capsulorrhaphy on the reduction of glenohumeral joint volume to determine the
optimal amount of capsular tissue to release and shift. Thirteen cadaveric
shoulders were dissected, viscous liquid was injected, and baseline volume was
recorded. The inferior axillary pouch was not eliminated until capsular
release had been carried out to the 4 o'clock position prior to capsular
shift.
Anterior Instability
Bottoni summarized the findings of a prospective, randomized clinical trial
comparing arthroscopic and open anterior shoulder stabilization. Sixty-one
patients with recurrent anterior shoulder instability who had had a failure of
nonoperative treatment were randomized to undergo arthroscopic or open
stabilization. All procedures employed bioabsorbable suture anchors and
identical rehabilitation protocols. Postoperative failure was defined as
recurrent dislocation, symptomatic subluxation, or the presence of symptoms
that precluded a return to full duty. Outcome was assessed with use of a
variety of instruments. With the numbers available, no differences in outcome
were identified following open and arthroscopic stabilization after a mean
duration of follow-up of twenty-eight months.
Sachs evaluated the correlation between outcome and subscapularis function
in a study of thirty patients who were evaluated four years after open Bankart
repair. Seven patients (23%) demonstrated incompetent subscapularis function
as indicated by a positive lift-off test and a mean strength of only 27% of
that on the unaffected side. Overall, only 57% of the patients with a positive
lift-off test reported a good or excellent result and only 57% stated that
they would undergo the procedure again. In contrast, 91% of patients with a
negative lift-off test reported a good or excellent result and all stated that
they would undergo the procedure again.
Schroder presented the long-term outcomes of the modified Bristow procedure
in a cohort of fifty-four United States Naval Academy Midshipmen (fifty-seven
shoulders). Fifty-two shoulders in forty-nine patients were available for
evaluation after a mean duration of follow-up of twenty-six years. The mean
Rowe score was 82, with a 73% rate of good or excellent results. Five
shoulders sustained recurrent dislocations and three sustained recurrent
subluxations, for an overall rate of instability of 15%. Eight subsequent
procedures were performed, and eight patients received disability compensation
while on discharge from active duty. The study represents the longest known
follow-up of patients managed with the modified Bristow procedure and
demonstrated long-term results that were comparable with those of other open
procedures used for the treatment of instability. Neyton evaluated the factors
influencing the rate of recurrence following arthroscopic stabilization in a
study of ninety-one consecutive patients who were reviewed after a mean
duration of follow-up of thirty-three months. Fourteen patients (15%) had
recurrent instability, with six patients having dislocations, after a mean
interval of 17.6 months. The author concluded that glenoid or humeral bone
defects and deficient capsular tissue increased the risk of recurrent
instability and suggested that a Bristow-Latarjet reconstruction may be
appropriate for these patients. Suguya reported on a series of forty-one
consecutive patients (forty-two shoulders) who were managed with arthroscopic
osseous Bankart repair for the treatment of chronic recurrent traumatic
anterior glenohumeral instability. All shoulders underwent preoperative
evaluation with use of three-dimensional computed tomography, which confirmed
an osseous glenoid rim fragment that averaged 9% of the surface area and an
average glenoid bone loss of 25%. At the time of arthroscopy, the osseous
fragment was firmly attached to the capsulolabral complex in all shoulders.
The fragment was separated from the glenoid neck prior to reduction and
fixation with use of suture anchors. After a mean duration of follow-up of
thirty-three months, thirty-nine shoulders (93%) were rated as good or
excellent and the mean Rowe score improved from 34 to 94 (p < 0.01). All
but two of the thirty-eight patients who had been active in sports returned to
their pre-injury level of sports activity.
Posterior Instability
Chhabra reported on 100 athletes in whom posterior instability was treated
with arthroscopic capsulolabral reconstruction with use of suture anchors and
capsular plication but without rotator interval repair. After a mean duration
of follow-up of two years, no strength deficits were noted. There was a mean
3° loss of external rotation and a similarly modest deficit in internal
rotation. All but five patients had a stable shoulder, and 83% of the athletes
returned to their previous level of sports activity. Seventy percent of the
patients had an excellent ASES score, and 20% had a satisfactory score. The
study highlights the success of this operation and suggests that closure of
the rotator interval does not appear to be necessary in contact athletes. In
contrast, Basmania concluded that rotator interval tissue deficiency may
explain posterior shoulder instability and the poor outcome following
anteriorly based shifts. Fifteen patients with posterior instability and
multidirectional instability who already had had failure of at least one
previous procedure underwent diagnostic arthroscopy followed by reconstruction
of the coracohumeral ligament with use of all or part of the coracoacromial
ligament. A Krakow suture was placed in the coracoacromial ligament after
release from the acromial undersurface. One arm of the suture was passed
through the supraspinatus tendon, the other arm was passed through the
subscapularis, and a portion of the lateral aspect of the rotator interval was
imbricated over the ligament transfer. After a minimum duration of follow-up
of two years, twelve patients reported an excellent result. The procedure
recreates an anteriorly-based tether against posterior instability with use of
a strong local tissue graft, without compromising the subscapularis. Holt
reached a similar conclusion about the role of the rotator interval following
a retrospective review of 102 arthroscopic posterior shoulder reconstructions
in ninety-seven patients. The author suggested that arthroscopic stabilization
is successful in most patients but that rotator interval and adjunctive
anterior repair may enhance shoulder stability.
Multidirectional Instability
Thigpen used an electromagnetic tracking system to analyze scapular
kinematics during forward flexion in twelve patients with multidirectional
instability and twelve matched controls. During arm descent, the scapula
rotated internally in patients with multidirectional instability and
externally in control subjects. The scapula tipped significantly more
posteriorly in patients with multidirectional instability than in control
subjects (p < 0.05). These differences highlight a lack of dynamic control
or a compensatory movement strategy and help to confirm patterns of scapular
dyskinesis in patients with multidirectional instability.
Complications
McCluskey reported on the use of Achilles tendon allograft augmentation in
a study of twenty-six patients with anterior subscapularis and capsular
deficiency and recurrent anterior instability. The patients had a mean age of
twenty-four years at the time of surgery and havd undergone a mean of 2.2
previous procedures for the treatment of instability. After a mean duration of
follow-up of forty-one months, the average ASES score had improved from 22 to
86 and the average visual analog score for pain had decreased from 8.9 to 2.1.
Eighty-eight percent of the patients were satisfied with the procedure and
considered the shoulder to be stable for activities of daily living and
work.
Glenohumeral Arthritis
Basic Science
Matsen presented a canine model of nonprosthetic arthroplasty to test the
hypothesis that reaming of the glenoid to a uniform concavity allows for the
regeneration of a stabilizing, remodeling, viable glenoid soft-tissue surface.
Twelve mature dogs that underwent humeral hemiarthroplasty coupled with
glenoid reaming were killed at either ten or twenty-four weeks. At twenty-four
weeks, the shoulders demonstrated complete coverage of the glenoid bone with a
uniform concave layer of actively remodeling fibrocartilage supported by
trabecular bone. The mean thickness of this layer was nearly three times the
thickness of normal canine glenoid cartilage. The depth of the glenoid
concavity increased following reaming, from 5.6 mm at ten weeks to 6.9 mm at
twenty-four weeks, so that the angular stability provided by the remodeled
glenoid exceeded that of the native glenoid. The study has implications for
the treatment of humans, particularly young and active patients who may be at
risk for glenoid implant loosening following total shoulder arthroplasty.
Eccentric posterior glenoid erosion is common in patients with
osteoarthritis. Reaming to restore neutral glenoid version is generally
recommended, but guidelines are lacking on the degree of eccentric erosion
that can be corrected while preserving adequate bone stock to allow glenoid
implantation. Clavert, in a study of five cadaveric shoulders, simulated
>15° of retroversion, confirmed the retroversion with computed
tomography, prepared the glenoid, and inserted an appropriately sized, pegged
glenoid implant. The author suggested that simply reaming to lower the
anterior edge of a glenoid with >15° of retroversion narrows the
glenoid vault and risks penetration of the pegs of a glenoid component. In
such instances, it may be better to use bone-grafting to restore glenoid
orientation.
Clinical
Weber evaluated the efficacy of arthroscopic débridement for the
treatment of glenohumeral arthritis. Forty patients with a mean age of
fifty-eight years underwent the procedure over a twelve-year period. Although
86% of the patients reported good initial response after three months of
follow-up, only 33% remained satisfied after a minimum duration of follow-up
of two years. Six of the thirty-six patients who were available for follow-up
had undergone total shoulder arthroplasty during the study period. The author
concluded that although débridement remains an option for younger
patients with glenohumeral arthritis, short-term relief is the norm as the
procedure does not appear to alter disease progression.
Techniques of Conventional Prosthetic Arthroplasty
Barwood reported on a dual-radius glenoid component, intended for use in
shoulders with excessive glenoid wear, that has an internal radius to match
the curvature of the humeral head component and an external radius
corresponding to the native glenoid. After a mean duration of follow-up of
thirty-three months, fourteen patients had improvement in terms of pain,
clinical findings, and ASES scores. Eleven of these patients had complete
glenoid component seating, and three had >90% seating. Stable component
fixation was possible despite limited glenoid bone stock. Wright reported on
prosthetic hemiarthroplasty coupled with allograft glenoid resurfacing in a
study of eleven patients with a mean age of seventy years in whom glenoid
implantation was contraindicated because of inadequate glenoid bone stock or
cuff tear arthropathy. Significant improvement in both the total Shoulder Pain
and Disability Index score and the functional subset score was noted at the
time of the most recent follow-up (p < 0.05), but the pain subset score did
not improve. Active elevation and external rotation did not improve and
remained quite modest in this challenging group of patients. Nagda reported on
continuous intraoperative peripheral nerve monitoring in a study of thirty
consecutive shoulder arthroplasties. Impending compromise of nerve function
was signaled by sustained electromyographic activity and attenuation of
transcranial electrical motor-evoked potentials. Seventeen patients had thirty
episodes of nerve dysfunction during surgery. Nerve alerts were not
extinguished simply by removing retractors, but twenty-three alerts were
extinguished after repositioning the arm to a neutral position. The study
suggested that the prevalence of nerve injury during shoulder arthroplasty is
greater than has been previously reported. Positioning the arm at the end
range of motion should be avoided, especially at the time of revision surgery
and in patients with decreased preoperative motion. Intraoperative nerve
monitoring should be considered for patients who are at risk for nerve
injury.
Ponce reported on a novel subscapularis repair technique for shoulder
arthroplasty that employed a lesser tuberosity osteotomy. The lesser
tuberosity osteotomy technique was then used during eighty-two consecutive
total shoulder arthroplasties. A sixfold decrease in the rate of subscapularis
dysfunction was observed when the results of this new technique were compared
with those of soft tissue side-to-side repair. No nonunions and only one late
repeat tear occurred. The author concluded that the lesser tuberosity
osteotomy allows for a biomechanically sound repair with good postoperative
function.
Outcomes of Arthroplasty
Martin reported on the results of cementless total shoulder arthroplasty in
patients with rheumatoid arthritis. Fifty-five shoulders in forty-seven
patients were evaluated after a mean duration of follow-up of 7.6 years. The
mean modified ASES score improved from 17 to 78, and 90% of shoulders had
little or no pain. No significant differences were noted when this group was
compared with a cohort of patients with osteoarthritis who underwent total
shoulder arthroplasty during the same period. The clinical survival rate
according to the Kaplan-Meier method was 96% at five years and 85% at ten
years. The author concluded that outcome following cementless shoulder
arthroplasty appears to be similar to that following surgery involving the use
of cemented components but acknowledged that the rate of clinical failure is
slightly higher. Setter reported the results of a meta-analysis comparing
total shoulder arthroplasty and hemiarthroplasty for the treatment of primary
glenohumeral osteoarthritis. Twenty-four pertinent studies that had been
published between 1966 and 2004 were identified, comprising a total of 1941
patients. Compared with hemiarthroplasty, total shoulder arthroplasty provided
significantly greater pain relief (p < 0.001), forward elevation (p <
0.001), gain in forward elevation (p < 0.001), gain in external rotation (p
< 0.002), and patient satisfaction (p < 0.001). Although the overall
prevalence of revision surgery following total shoulder arthroplasty was 7.7%,
only 1% of all-polyethylene glenoid components required revision. The author
cautioned that the meta-analysis also served as a stark reminder that these
studies employed nonhomogeneous outcome instruments and that most demonstrated
a meager level of evidence.
Constrained Prosthetic Arthroplasty
Boileau reported on forty-five consecutive patients who underwent reverse
ball-and-socket arthroplasty and were followed for a minimum of twenty-four
months. The study group included patients with cuff-tear arthropathy, patients
with fracture sequelae with migration or nonunion of the tuberosities, and
patients with rotator cuff deficiency undergoing revision shoulder
arthroplasty. The study demonstrated substantial improvement in terms of both
active forward elevation (from 55° to 121°) and the Constant score
(from 17 to 59 points). No improvement in active external rotation or internal
rotation was noted. Overall, 67% of the patients had little or no pain and 78%
were satisfied. The patients in the cuff-tear arthropathy group had
significantly higher Constant scores (p < 0.05) and ASES scores (p <
0.005) than the patients in the revision group did. The complication and
revision rates were higher in the revision group (47% and 26%, respectively).
Overall, the reverse ball-and-socket arthroplasty improved function and
restored forward active elevation but did not improve active rotation. Results
were less predictable following fracture or revision surgery.
Complications and Revisions
Krishnan reported on the results of revision shoulder arthroplasty for
patients with a failed glenoid implant. Seventeen patients underwent
cancellous grafting of the glenoid defect followed by spherical reaming and
resurfacing with use of Achilles tendon allograft that was sewn into the
glenoid rim. Nine patients underwent revision implantation with use of a peg
glenoid allowing for bone ingrowth. After a minimum duration of follow-up of
two years, the mean ASES score had improved from 22 to 77 and the mean flexion
had improved from 70° to 124°. Postoperative radiographs revealed
consolidation of bone graft and sclerosis in all patients.
To determine the prevalence of deep-vein thrombosis following shoulder
arthroplasty, Willis prospectively followed 100 consecutive shoulder
replacements (including seventy-three total shoulder replacements) for twelve
weeks but excluded those in patients receiving routine anticoagulation
therapy. A four-limb surveillance color-flow Doppler ultra-sound examination
was performed two days and twelve weeks postoperatively for all patients.
Postoperative symptomatic pulmonary emboli were also recorded. Thirteen cases
of deep-vein thrombosis were identified in twelve patients, including seven
cases involving the lower extremity. All six upper extremity cases involved
the operative side. Ten of the thirteen cases were identified at two days, and
three were identified at twelve weeks. Three cases of pulmonary embolism were
identified, one of which was fatal. The prevalence of thromboembolic disease
following shoulder arthroplasty may be higher than previously appreciated.
Additional study is needed to determine the role of routine prophylaxis
against thromboembolic disease following shoulder arthroplasty.
Adhesive Capsulitis
Shaffer reported on the accuracy of intra-articular steroid injection in a
study of thirty consecutive patients with adhesive capsulitis. The injections
included radiopaque dye and were performed with use of a spinal needle through
one of three commonly used shoulder portals: posterior, supraclavicular
(Neviaser), and anterior. Of the ten posterior injections, only one was
intra-articular and one was partially intra-articular, for an accuracy rate of
15%. In contrast, of the ten anterior injections, nine were intra-articular
and one was partially intra-articular, for an accuracy of 95%. Interestingly,
all patients noted improved comfort and pain (as assessed with a visual analog
scale) had decreased by a mean of 39% following the injection, but with the
numbers available no significant differences were noted among the three
different methods. The study demonstrated that the accuracy of intra-articular
injection for the treatment of adhesive capsulitis is technique-dependent.
However, because the corticosteroid injections were effective irrespective of
injection accuracy, efficacy could not be attributed solely to intra-articular
placement.
Fractures
Proximal Humeral Fractures
Keenan reported on the outcomes following closed reduction and percutaneous
pinning of proximal humeral fractures. Thirty-six patients with a mean age of
sixty years were managed over a five-year period. The fracture patterns that
were treated included eleven two-part surgical neck fractures; nine three-part
greater tuberosity and surgical neck fractures; and sixteen valgus, impacted
four-part proximal humeral fractures. All fractures healed and thirty patients
were satisfied with the result of surgery, but the mean ASES score was 56 and
the mean internal rotation was to the third lumbar level. Two patients had
development of osteonecrosis and underwent prosthetic hemiarthroplasty, and
one patient had development of a joint contracture and underwent arthroscopic
capsular release. The authors noted that the procedure was associated with a
high rate of fracture union, good clinical results, and a low rate of
complications but also observed that mild residual shoulder pain and stiffness
were common.
Weinstein studied the torsional stiffness provided by two types of plates
used to treat proximal humeral fractures. A three-part fracture was created in
each of six pairs of cadaveric humeri. One specimen of each pair was repaired
with a proximal humeral locking plate, and the other was repaired with an
angled blade-plate. The mean initial torsional stiffness was nearly twice as
high for the locking plate as for the blade-plate, and the number of cycles to
failure was higher for the locking plate (p < 0.05). These findings suggest
that the locking plate may allow for earlier postoperative motion.
Gonzalez-Hernandez reported on the results of rigid fixation of proximal
humeral fractures in older adults. Twenty-seven consecutive patients who were
more than sixty-five years old and who had three and four-part fractures
underwent open reduction and internal fixation with use of a modular
fixed-angle plate and transosseous wires. After a minimum duration of
follow-up of twelve months, all fractures had healed. Pain control was good or
excellent in all but two patients, and range of motion was excellent in
twenty-one patients. Most patients were able to return to their pre-injury
level of function. The study did not explicitly select valgus impacted
four-part fractures, and osteonecrosis was not observed in this group of
patients after short-term follow-up. Nevertheless, open reduction and internal
fixation of three and four-part fractures may be an alternative to prosthetic
hemiarthroplasty in older adults with osteopenic bone. Boileau reported on the
treatment of proximal humeral fractures with use of a shoulder prosthesis
specifically designed for fracture. The prosthesis is characterized by a
medialized neck to facilitate tuberosity placement and by a metaphyseal window
that holds bone graft excavated from the humeral head to aid with tuberosity
healing. A positioning guide helps to adjust prosthetic retroversion and
height and facilitates component trialing. The results in seventy-two patients
were reviewed after a minimum duration of follow-up of twelve months. The mean
active forward elevation was 107°, and the mean adjusted Constant score
was 73. The tuberosities were positioned appropriately in 67% of the cases,
but in the remaining cases they had migrated or were malpositioned. Humeral
height was restored to within 10 mm of the native height in 70% of the cases
in which the positioning guide was employed and in 30% of the cases in which
it was not. Outcome was positively correlated with surgeon experience, the use
of bone-grafting, and anatomic tuberosity position. Smith reviewed the results
of operative treatment of 116 proximal humeral fractures. The overall
complication rate for ninety-three fractures that were treated with internal
fixation was 58%, with twenty-two shoulders requiring additional surgery.
Fourteen shoulders demonstrated initial fragment malpositioning and, of the
eighty-two shoulders that were followed for more than three months, seventeen
demonstrated fracture displacement, eighteen demonstrated malunion, and
seventeen demonstrated delayed union. Fractures that were treated with
fixed-angle plates had lower rates of initial malpositioning and malunion. The
study reaffirmed that complications following the operative treatment of
proximal humeral fractures are common. The author suggested that the primary
goal of operative treatment should be a stable shoulder with healed
tuberosities.
Clavicular Fractures
Verborgt presented the results of plate fixation for acute displaced
midshaft clavicular fractures in thirty-nine semiprofessional athletes with a
mean age of twenty-six years. At six weeks postoperatively, the mean Constant
score was 88 and the visual analog score for pain was 3 of 10. The mean time
to return to sports activity was forty-five days. Two patients sustained a
refracture following new trauma, but thirty-seven fractures had united
radiographically by eighteen weeks. Seventy-five percent of the patients were
very satisfied, and 95% stated that they would choose the same operation
again. The study suggested that early internal fixation of displaced mid-shaft
clavicular fractures in athletes facilitates an early return to sports
activity.
McKee reported on the effect of time to surgery on the outcome of open
reduction and internal fixation for the treatment of clavicular fracture
nonunion. Thirty-eight patients, with a mean age of forty-three years,
underwent surgery for the treatment of a nonunion that had persisted for a
mean of 2.1 years. All fractures were treated with plate fixation, and 64%
were treated with iliac crest bone-grafting. Two patients required revision
surgery, but the fractures in the remaining patients healed uneventfully.
Surgery for the treatment of clavicular fracture nonunion was associated with
a high rate of patient satisfaction and a low rate of residual disability,
irrespective of the timing of surgery.
Miscellaneous
Hawkins evaluated the psychometric properties of the ASES score with use of
a large database comprising over 1000 patients with shoulder instability,
rotator cuff disease, and glenohumeral arthritis. The ASES shoulder scale
demonstrated acceptable test-retest reliability, with an intraclass
correlation coefficient of 0.94. The ASES scale demonstrated acceptable
internal consistency for patients with instability (Cronbach's alpha = 0.61),
rotator cuff disease (0.64), and glenohumeral arthritis (0.62). The study
validated the use of the ASES shoulder scale for the evaluation of patients
with shoulder instability, rotator cuff disease, and glenohumeral arthritis.
Schell reviewed closed malpractice cases involving the shoulder, arm, and
elbow over a twenty-year period at a large physician-owned medical malpractice
insurance company. Of the 133 closed lawsuits, 61% resulted in indemnity for
the plaintiff. Overall, 96% of shoulder claims involved adults and 58% of
elbow claims involved children. Eighty-three percent of pediatric claims were
related to the elbow. Surgical error accounted for 62% of allegations, whereas
improper nonoperative treatment accounted for 20% and diagnosis failure
accounted for 18%. The most common surgical errors were improper fracture
treatment (32%), hardware failure (18%), neuropathy (12%), and insufficient
surgery (12%). Trauma claims paid out twice that of elective claims, and
fellowship training had no positive or negative effect on case outcomes. Five
of the eight claims related to shoulder dislocation involved a missed
posterior dislocation. Claims involving the humeral shaft were associated
either with radial nerve injury or with plate failure. All pediatric elbow
claims involved fractures.
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Elbow
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Instability
Basic Science
Koh tested the hypothesis that the flexor carpi ulnaris significantly
reduces loading of the ulnar collateral ligament, which is the primary static
restraint to valgus elbow rotation. The study demonstrated that the flexor
carpi ulnaris was an important dynamic stabilizer of the elbow to valgus
forces and that moments occurred at the elbow about axes other than
flexion-extension. Park employed a cadaveric model to study the dynamic
contributions of the flexor-pronator muscles to valgus elbow stability. Medial
collateral ligament tears were created in six cadaveric elbows, and the elbow
kinematics resulting from different patterns of muscle-loading were measured.
When compared with the intact ligament without muscle-loading, medial
collateral ligament detachment produced a 5° valgus instability. Flexor
carpi ulnaris stimulation corrected the instability nearly to the intact
state. Both studies highlighted the importance of the flexor carpi ulnaris in
injury prevention, intraoperatively, and during rehabilitation in patients
with valgus instability.
Clinical
Willis reported on a new test for the diagnosis of posterolateral rotatory
elbow instability, in which a posteriorly directed force is applied to the
radial head anteriorly and translation of the radiocapitellar joint is
evaluated. The test was applied preoperatively to six patients with surgically
documented lateral ulnar collateral ligament insufficiency. All patients had a
positive posterolateral rotatory drawer test and tolerated this new test
without pain or apprehension. In contrast, the pivot-shift test was negative
for two patients and could not be performed for three patients because of
apprehension. The cadaveric study demonstrated that the radiocapitellar
translation averaged 5 mm and was most pronounced between 60° and 120°
of elbow flexion. Large reported on the results of a biomechanical comparison
between Jobe and metal inference screw reconstructions of the ulnar collateral
ligament. The stiffness of the intact ulnar collateral ligament in ten matched
pairs of cadaveric elbows was tested under nondestructive valgus loading at
different angles of elbow flexion. Each matched pair then had reconstruction
of the anterior bundle with use of matched hamstring tendons with use of the
Jobe or interference screw technique. Testing was repeated to compute
stiffness, and the specimens were then tested to failure. The initial
stiffness of the Jobe reconstruction was not significantly different from that
of the intact ligament, but the interference screw construct was not as stiff.
At each angle of elbow flexion, the Jobe reconstruction had superior
biomechanical properties than did the interference screw construct, which
typically failed as a result of tunnel slippage.
Tendon Injuries
Basic Science
Mullett presented the results of a cadaveric and clinical study of lateral
epicondylitis. Arthroscopic examination of the radiocapitellar joint
demonstrated a band of tissue that was confluent with the orbicular ligament
in sixteen of thirty-four cadaveric elbows. Twenty-five patients underwent
arthroscopic surgery for the treatment of recalcitrant lateral epicondylitis
and had resection of a collar-like band of tissue that subluxated with forearm
rotation. All but two patients had complete resolution of symptoms.
Histological examination of the resected tissue demonstrated hyaline
degeneration. The author implicated impingement of this degenerative band
within the radiocapitellar joint in the pathogenesis of lateral
epicondylitis.
Clinical
Rompe tested the hypothesis that repetitive low-energy extra-corporeal
shock wave treatment is superior to placebo in tennis players with chronic
lateral epicondylitis. Seventy-eight tennis players with tennis elbow of at
least twelve months' duration were randomized to receive either active shock
wave treatment (given weekly for three weeks) or placebo. At three months,
there was significantly greater improvement with regard to pain during
resisted wrist extension in the treatment group as compared with the placebo
group (p < 0.005). Improvement in upper extremity function, measured with
use of a specific outcome scale, was also significantly greater in the
treatment group (p < 0.001). Sixty-five percent of the patients in the
treatment group achieved at least a 50% reduction in pain, compared with 28%
of the patients in the placebo group. Szabo compared three methods of
operative treatment in a study of patients with recalcitrant lateral
epicondylitis; the procedures included twenty-four percutaneous releases,
forty-four arthroscopic procedures, and forty-one open procedures. After a
mean duration of follow-up of forty-eight months, failure (defined as the need
for additional operative intervention or a poor outcome) occurred in three
(13%) of the patients who had had a percutaneous release, in one (2%) of the
patients who had had an arthroscopic release, and in two (5%) of the patients
who had had an open release. The author concluded that all three methods are
highly effective for the treatment of recalcitrant lateral epicondylitis. John
reported on the outcome of single-incision repair for the treatment of acute
distal biceps tendon ruptures with use of two suture anchors placed in the
radial tuberosity through a limited transverse incision in the antecubital
fossa. Fifty-one of sixty consecutive patients who underwent this procedure at
a mean age of forty-six years were evaluated after a mean duration of
follow-up of thirty-five months. There were forty-five excellent and six good
outcomes, with no fair or poor results. Cybex testing demonstrated a 5%
decrease in elbow flexion and a 7% decrease in supination strength compared
with the contralateral extremity, but these differences were not significant,
with the numbers available. Two patients had development of heterotopic
ossification that resulted in slightly limited forearm rotation and mild pain.
This rather large study demonstrated the efficacy of the single-incision
technique for distal biceps tendon repair. Jost reported on the excision of a
proximal radioulnar synostosis in twelve patients in whom this complication
developed following acute distal biceps repair. The excision was carried out
as early as two months and as late as eighteen months after repair. All
patients received indomethacin for four weeks postoperatively, and six
patients also received radiation treatment. Preoperatively, the mean arc of
rotation was 19° and six elbows were ankylosed in a neutral position.
After a mean duration of follow-up of fifty-nine months, the mean arc of
rotation had improved to 138° (p < 0.001). No complications were
encountered during or after excision, and radiographs demonstrated no
recurrence of ectopic bone.
Fractures and Dislocations
Capo determined that plain radiographs are ineffective for assessing radial
head fractures. Three independent physicians compared the radiographic
features of sixteen radial head fractures with the findings on preoperative
computed tomography scans and with intraoperative findings. Compared with
intraoperative findings, plain radiographs underestimated the degree of head
involvement in ten cases and overestimated the degree of head involvement in
six cases. The mean error was 17%. The number of radial head fragments was
overestimated in seven cases, underestimated in six, and correct in only
three. When the guidelines for operative treatment are 30% head involvement,
more than three fragments, and 2 mm of step-off, interpreting plain
radiographs alone may lead to incorrect treatment choices. Smith compared the
results of plate fixation with those of low-profile fixation for the treatment
of proximal radial head and neck fractures after an average duration of
follow-up of 3.8 years. Twenty patients underwent internal fixation of a Mason
type-2 or 3 radial head or neck fracture with use of plates (ten patients) or
with use of screws or threaded pins (ten patients). The author suggested that
plate fixation leads to less forearm rotation and higher rates of heterotopic
bone formation compared with fixation that avoids extensive annular ligament
dissection and hardware placement along the radial neck.
The medial collateral ligament is the primary elbow restraint to valgus
load, and the interosseous membrane is the primary stabilizer of the
radioulnar relationship. Hartman evaluated the role of the radial head as a
secondary elbow and radioulnar stabilizer and assessed the effectiveness of
radial head replacement in reproducing these roles. A valgus elbow moment was
produced in seven cadaveric upper extremities, and the resultant medial
collateral ligament and interosseous ligament strains were measured. After
radial head replacement with a modular press-fit implant, the strains returned
to within 2% of the strains observed in the intact specimens. The study
suggested that radial head replacement maintains the role of the native radial
head as a secondary stabilizer of the forearm and elbow.
Doornberg described the use of coronoid process landmarks that were
identified on three-dimensional computed tomography scans as reference points
for proper sizing of a radial head implant. The author suggested that a radial
head implant should be placed so that its articular surface is just slightly
more prominent than the coronoid articular surface. Preoperative radiographs
of the contralateral elbow aid in templating and help to prevent overstuffing
the joint. Forth-man reported on the results of treatment of acute traumatic
elbow instability without medial collateral ligament repair in a study of
thirty-four patients at a mean of twenty-one months after injury. All
procedures involved repair of the ulna and coronoid, repair or replacement of
the radial head, and repair of the lateral collateral ligament complex. A
stable, mobile articulation (mean flexion-extension arc, 101°) was
restored in all patients. The author concluded that medial collateral ligament
repair is rarely necessary for the treatment of complex acute traumatic elbow
instability. Kamineni reviewed the results of total elbow arthroplasty for the
treatment of acute distal humeral fractures in a study of forty-three patients
with a mean age of sixty-seven years. The mean flexion-extension arc was
24° to 132°, and the mean Mayo elbow performance score was 93.
Heterotopic ossification was present in seven cases and additional surgery was
required in ten cases, including five cases in which revision arthroplasty was
required. The study suggested that total elbow arthroplasty should be
considered whenever there is potential for distal humeral nonunion, especially
in the physiologically older, lower-demand patient.
Stiffness
Posttraumatic elbow stiffness is a common complication. Recovery of range
of motion, especially extension, is often hampered by elbow flexor spasm.
Rosenwasser tested the hypothesis that intraoperative injection of botulinum
toxin A (Botox) would prevent elbow stiffness and enhance elbow function by
causing transient muscle paralysis. Twelve patients with a mean age of sixty
years who had sustained a fracture or fracture-dislocation about the elbow
were randomized to receive an intraoperative injection of Botox or normal
saline solution into both the brachialis and biceps brachii muscles. These
preliminary findings support the adjunctive intramuscular injection of
botulinum toxin A during the operative treatment of elbow fractures and
fracture-dislocations to prevent posttraumatic elbow stiffness.
Arthritis
Silva presented the results of forty-two radial head excisions in
thirty-seven patients with hemophilic elbow arthropathy. Thirty-three percent
of the patients were positive for the human immunodeficiency virus, and seven
elbows had undergone previous surgery. After a mean duration of follow-up of
5.8 years, the flexion-extension arc was essentially unchanged but the
pronation-supination arc had significantly improved by 61° (p <
0.0001). After a mean interval of five years, a second procedure was required
in nine elbows; the procedures included six synovectomies for persistent elbow
bleeding, one total elbow arthroplasty, and two ulnar nerve transpositions.
The study demonstrated that radial head excision in patients with hemophilia
improves forearm rotation and can be performed safely.
Miscellaneous
Kim reported on the arthroscopic treatment of posterolateral elbow
impingement resulting from synovial plicae in a study of twelve patients who
were either throwers or golfers. None of the patients had lateral
epicondylitis, all patients had postero-lateral elbow pain, and seven patients
complained of clicking or catching. At the time of arthroscopy, a thickened
lateral synovial plica was identified and débrided. After a mean
duration of follow-up of thirty-four months, eleven patients reported an
excellent outcome. Patients returned to competitive sports activity at an
average of five months postoperatively. John reported on an aggressive
nonoperative treatment protocol that was used for thirty-eight patients with
osteochondritis dissecans of the capitellum who were followed for a minimum of
twenty-four months. Patients who were without symptoms associated with loose
bodies and who had an intact cartilage cap on magnetic resonance imaging were
allowed to continue athletic activity with the elbow in a double-hinged brace
that allowed only pain-free motion. Patients who met the criteria for
operative intervention at any point during treatment underwent arthroscopic
removal of loose bodies, débridement, and drilling of the lesion.
Seventeen of twenty-three patients who were managed with the brace avoided
surgery, and 88% returned to their previous level of sports activity. All
patients who were managed nonoperatively had a good or excellent result.
Eighteen of the nineteen patients who were managed operatively had a good or
excellent result. The study suggested that many patients with osteochondritis
dissecans of the capitellum can be managed successfully without immobilization
or cessation of activity. Naidu used the decrease in ulnar nerve conduction
velocity across the elbow to compute the probability of the diagnosis of
cubital tunnel syndrome. One hundred normal nerve conduction studies in 100
normal subjects and 100 studies in patients with the clinical diagnosis of
cubital tunnel syndrome were evaluated with logistic regression analysis. The
analysis demonstrated that even a 20% reduction in conduction velocity across
the elbow predicted cubital tunnel syndrome with 70% likelihood. A 25%
reduction predicted cubital tunnel syndrome with 80% likelihood. A 40%
reduction predicted cubital tunnel syndrome with 95% likelihood. The findings
refuted the classic teaching that a one-third decrease in conduction velocity
is always clinically important. Cubital tunnel syndrome remains a clinical
diagnosis, and nerve conduction velocity studies merely verify its
presence.
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Evidence-Based Orthopaedics
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The editorial staff of The Journal reviewed a large number of
recently published research studies related to the musculoskeletal system that
received a Level of Evidence grade of I. Over 100 medical journals were
reviewed to identify these articles, which all have high-quality study design.
In addition to articles published previously in this journal or cited already
in this Update, five level-I articles were identified that were relevant to
shoulder and elbow surgery. A list of those titles is appended to this review
after the standard bibliography. We have provided a brief commentary about
each of the articles to help to guide your further reading, in an
evidence-based fashion, in this subspecialty area.
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Appendix: Evidence-Based Articles Related to the Shoulder and Elbow
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Shoulder
Fabbriciani C, Milano G,
Demontis A, Fadda S, Ziranu F, Mulas PD. Arthroscopic versus open
treatment of Bankart lesion of the shoulder: a prospective randomized study.
Arthroscopy.2004
;20:456
-62[Medline]
Sixty patients with traumatic anterior shoulder instability were divided
into two groups; thirty patients underwent an arthroscopic repair, and thirty
patients had an open procedure. Both groups underwent repair with use of
metallic anchors and nonabsorbable sutures. Two-year follow-up included
Constant and Rowe shoulder scores. The only significant difference between the
groups was in the active range of motion as measured with the Constant score,
which was significantly improved in the arthroscopic repair group. No
recurrence of dislocation was reported in either group. The authors concluded
that arthroscopic repair with suture anchors is an effective technique and
that open repair can negatively affect the recovery of full range of motion.
The findings of this study contrast with the experience of Weber as described
earlier.
Teefey SA, Rubin DA,
Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and
quantification of rotator cuff tears. Comparison of ultra-sonographic,
magnetic resonance imaging, and arthroscopic findings in seventy-one
consecutive cases. J Bone Joint Surg Am.2004
;86:708
-16.[Abstract/Free Full Text]
One hundred and forty-five consecutive patients were studied with
ultrasonography and magnetic resonance imaging. Seventy-one patients had
subsequent arthroscopy, and those seventy-one patients formed the study group.
Ultrasonography correctly predicted the degree of retraction of 73% of the
full-thickness tears and the length of 85% of the partial-thickness tears,
whereas magnetic resonance imaging correctly predicted 63% and 75%,
respectively. Ultrasonography correctly predicted the width of 87% of the
full-thickness tears and 54% of the partial-thickness tears, whereas magnetic
resonance imaging correctly predicted 80% and 75%, respectively. In expert
hands, such as those of the senior author, ultrasonography is an accurate
method of rotator cuff assessment and allows the orthopaedic surgeon to select
the appropriate test on the basis of other factors, such as clinical
information regarding lesions of the glenoid labrum, joint capsule, or
surrounding muscle or bone; the presence of an implanted device; patient
tolerance; and cost.
Gartsman GM, O'Connor DP.
Arthroscopic rotator cuff repair with and without arthroscopic subacromial
decompression: a prospective, randomized study of one-year outcomes.
J Shoulder Elbow Surg.2004
;13:424
-6.[CrossRef][Medline]
Gartsman and O'Connor used an arthroscopic technique to repeat the
pioneering work of Matsen, who found that the results of open rotator cuff
repair demonstrated no improvement when acromioplasty was added to the rotator
cuff repair. Similarly, Gartsman and O'Connor reported that the results of
arthroscopic rotator cuff repair were no different between patients who had
been randomized to cuff repair with or without arthroscopic subacromial
decompression. The study group was confined to patients with a type-2 acromion
and a full-thickness supraspinatus tear. Follow-up was limited to one year,
and the outcome was determined on the basis of patient self-assessment.
Nonetheless, this study further complicates the surgeon's decision-making by
calling into question both the role of acromioplasty in patients who are
managed with operative repair of a full-thickness rotator cuff tear and the
theory of external, extrinsic compression as a cause of rotator cuff lesions.
Additional study is necessary before a definitive conclusion can be
reached.
Elbow
Hayton MJ, Santini AJ, Hughes
PJ, Frostick SP, Trail IA, Stanley JK. Botulinum toxin injection in the
treatment of tennis elbow. A double-blind, randomized, controlled, pilot
study. J Bone Joint Surg Am.2005
;87:503
-7.[Abstract/Free Full Text]
The authors studied the effects of botulinum injection in this prospective,
randomized, double-blind clinical trial. Forty patients were divided into two
equal groups. One group received 50 U of botulinum toxin type A, and the other
group received normal saline solution. Three months following the injections,
there was no significant difference between the two groups with regard to grip
strength, pain, or quality of life. There appears to be no benefit associated
with the use of botulinum injection for the treatment of tennis elbow.
Dunkow PD, Jatti M, Muddu
BN. A comparison of open and percutaneous techniques in the surgical
treatment of tennis elbow. J Bone Joint Surg Br.2004
;86:701
-4.
The authors conducted a prospective, randomized trial of forty-seven elbows
in forty-five patients. The patients were preoperatively and postoperatively
assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) scoring
system. Both groups were followed for a minimum of twelve months. The patients
undergoing percutaneous tenotomy release returned to work an average of three
weeks earlier and improved significantly more quickly than those undergoing an
open procedure did. It appears that the quicker and simpler procedure produces
significantly better results.
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