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The Journal of Bone and Joint Surgery (American). 2007;89:220-230. doi:10.2106/JBJS.F.01417 © 2007 The Journal of Bone and Joint Surgery, Inc. What's New in Shoulder and Elbow Surgery
1 Penn Orthopaedic Institute, Penn Presbyterian Medical Center, One Cupp
Pavilion, 39th and Market Streets, Philadelphia, PA 19104. E-mail address for
M. L. Ramsey:
Matthew.Ramsey{at}UPHS.upenn.edu
Specialty Update has been developed in collaboration with the Council
of Musculoskeletal Specialty Societies (COMSS) of the American Academy of
Orthopaedic Surgeons.
This annual update on shoulder and elbow surgery is based on a review of presentations at meetings of the Arthroscopy Association of North America (Specialty Day, March 25, 2006, Chicago, Illinois; Twenty-fifth Annual Meeting, May 18 to 21, 2006, Hollywood, Florida), the American Shoulder and Elbow Surgeons (Twenty-second Open Meeting, Specialty Day, March 25, 2006, Chicago, Illinois; Twenty-third Closed Meeting, September 13 to 15, 2006, Chicago, Illinois), The American Orthopaedic Society for Sports Medicine (Specialty Day, March 25, 2006, Chicago, Illinois), the American Academy of Orthopaedic Surgeons (Seventy-third Annual Meeting, March 22 to 25, 2006, Chicago, Illinois), and the Orthopaedic Research Society (Fifty-second Annual Meeting, March 19 to 22, 2006, Chicago, Illinois).
Rotator Cuff Basic Science Park proposed a transosseous equivalent rotator cuff repair technique and performed a biomechanical study to evaluate footprint contact pressure in a variety of repair configurations. A "suture-bridging" technique utilizing medial anchors with suture limbs traversing over the cuff to a lateral interference screw attachment was compared with a double-row anchor repair. A four-limb suture bridge (two medial anchors with four limbs over the cuff laterally) established a significantly higher mean contact pressure area (72.3%) compared with a two-limb suture bridge (57.3%) and a double-row repair (35.1%) (p < 0.05). The authors concluded that increasing footprint contact pressure may aid in rotator cuff healing.
Impingement
Partial-Thickness Tears The healing rate of partial-thickness rotator cuff tears following arthroscopic takedown and repair was evaluated by Yamaguchi. Forty-three patients were followed prospectively to evaluate healing following arthroscopic takedown (completion) and repair of the tears. Healing of the rotator cuff was assessed with ultrasound six months after surgery. The repair was intact in thirty-eight (88%) of the forty-three patients and was retorn in five. The average American Shoulder and Elbow Surgeons (ASES) score improved from 46.1 to 79.7, and the overall rate of patient satisfaction was 93%. The authors did not note the depth and size of the tears prior to completion. However, the healing rate for these patients exceeds that for patients with full-thickness tears. These results support completion of partial rotator cuff tears followed by repair.
Full-Thickness Tears Liem evaluated the influence of fatty infiltration and atrophy on the outcome of arthroscopic repair of isolated supraspinatus tears in a study of thirty-two consecutive patients with a minimum of twenty-four months of follow-up. Six patients (18.8%) were found to have a retear on postoperative magnetic resonance imaging. The supraspinatus atrophy was significantly greater preoperatively (at least grade 2) in the re-tear group as compared with the healed group. The presence of atrophy decreased the clinical outcomes in patients with a healed rotator cuff as compared with patients who had a healed rotator cuff in the absence of atrophy. The degree of fatty infiltration of the supraspinatus and infraspinatus was significantly higher in the retear group as compared with the healed group. In addition, fatty infiltration appeared to progress in the retear group and remained static in the healed group. The authors concluded that preoperative magnetic resonance imaging evaluation of the degree of atrophy and fatty infiltration of the rotator cuff muscles has a significant influence on clinical outcome. Members of the French Arthroscopy Society conducted a multicenter retrospective review of 576 arthroscopically repaired rotator cuff tears. All were isolated tears of the posterosuperior part of the rotator cuff, and tears involving the subscapularis were excluded from the study. The patients were evaluated postoperatively with computed tomography or magnetic resonance imaging arthrography and were rated with use of the Constant score. Overall, recurrent tears were found in 25.2% of the shoulders, with a complication rate of 3.1% (including a 2.7% rate of reflex sympathetic dystrophy, a 0.2% rate of infection, and a 0.2% rate of anchor migration). The overall Constant score and its subcategory scores for strength, mobility, and activity were found to have a highly significant correlation with the integrity of the rotator cuff repair; however, pain scores did not correlate with tendon healing. Clinical results and healing rates also were found to be strongly correlated with preoperative tear size, retraction, intrasubstance tears, fatty degeneration, and the age of the patient. Work-related injuries were correlated with poor clinical results.
Massive and Irreparable Tears Gerber and associates investigated whether the integrity of the teres minor musculotendinous unit was predictive of outcome following latissimus dorsi tendon transfer. Twenty-two patients who underwent latissimus dorsi tendon transfer for the treatment of massive, irreparable posterosuperior rotator cuff tears were retrospectively reviewed. Sixteen men and six women with a mean age of fifty-eight years (range, forty to sixty-eight years) were analyzed after an average duration of follow-up of thirty-four months (range, twenty-four to fifty-seven months). Fatty infiltration of the teres minor was classified as Goutallier stage 0 in five patients, stage 1 in six patients, stage 2 in four patients, stage 3 in six patients, and stage 4 in one patient. Eleven patients had a partial tear of the teres minor tendon, and two patients had a complete tear. Increased fatty infiltration of the teres minor that was classified as greater than stage 2 was associated with worse postoperative Constant scores (p = 0.015), age-adjusted Constant scores (p = 0.012), active external rotation (p = 0.016), and active elevation (p = 0.012). Simply the presence or absence of a tear of the tendon had no significant effect on the outcome.
Complications
Biceps Tendon
Glenohumeral Instability Tjoumakaris investigated the functional outcomes for patients who had undergone arthroscopic or open stabilization for the treatment of recurrent anterior instability. The outcomes for twenty-four patients who had had open shoulder stabilization and sixty-nine patients who had had arthroscopic shoulder stabilization were compared by means of a modified ASES score. The patients had a minimum of two years of follow-up, with the repair method chosen by surgeon preference. There was a single recurrence of instability in both the open group and the arthroscopic group. There was no difference between the groups with regard to the overall modified ASES scores or the subscores for pain, satisfaction, and function. The authors stated that recurrent instability may not be the most appropriate parameter with which to measure success. Instead, they believed that functional outcome measures are more appropriate, demonstrating equivalent results between open and arthroscopic instability surgery. The ability of contact athletes to return to sports activity following arthroscopic anterior shoulder stabilization was investigated by Williams. Twenty-four patients who had undergone twenty-eight procedures were retrospectively reviewed. Patients were selected on the basis of a history of involvement in contact sports, recurrent anterior instability, and arthroscopic stabilization. Patients were excluded if they demonstrated either glenoid or humeral bone loss or had had previous shoulder surgery. All patients had a minimum of two years of follow-up. Twenty-one patients (88%) were able to return to contact sports at the same level. Seven patients did not return to contact sports, with only one of these seven patients not returning to sports because of continued problems with the shoulder. Two patients had recurrent instability, with one requiring revision surgery. Functional outcomes as measured with use of the ASES score, the L'Insalata score, and the Western Ontario Shoulder Instability Index (WOSI) were excellent both in patients who returned to contact sports and in those who did not. The authors concluded that arthroscopic shoulder stabilization for the treatment of recurrent anterior instability in selected patients provides an excellent functional outcome and can successfully return contact athletes to play. In a prospective study, Mochizuki et al. compared arthroscopic Bankart repairs involving the use of suture anchors in high-demand and lower-demand patient populations with traumatic anterior glenohumeral instability. Ninety-nine shoulders in ninety-nine patients with traumatic unilateral anterior shoulder instability were evaluated on the basis of the Rowe score, the rate of recurrence, the return to activity, and the range of motion as measured by an independent examiner at an average of thirty-eight months after arthroscopic surgery. Of the ninety-nine shoulders, fifty-eight were in high-demand patients participating in judo, karate, boxing, gymnastics, wakeboarding, snowboarding, basketball, handball, or rugby. In these fifty-eight high-demand patients, the average Rowe score improved from 30.2 to 92.4 points. This finding was not different from that in the group of lower-demand patients, in whom the score improved from 31.5 to 90.6 points. The high-demand patients lost a mean of 4° of external rotation in adduction. This finding also was not different from that in the group of lower-demand patients, who lost a mean of 3° of external rotation in adduction. The recurrence rate in the group of high-demand patients (3.4%, two of fifty-eight) was lower than that in the group of lower-demand patients (4.9%, two of forty-one). All patients were able to return to their sports at the same level or a higher level following surgery.
Posterior Instability
Glenohumeral Arthritis Craig and colleagues evaluated the glenoid components that had been retrieved from sixty-five shoulders over a twenty-six-year period. The original total shoulder replacements had been performed for a variety of diagnoses, including osteoarthritis, posttraumatic arthritis, inflammatory arthritis, and osteonecrosis. The components had been removed because of aseptic loosening in 81.5% of the cases and septic loosening in 18.5%. The authors found several common patterns of glenoid wear. Scratching and pitting of the glenoid were found most commonly on the inferior portion of the component and represented the most common form of wear. Edge deformation was found in thirty-one (47.7%) of the specimens. Abrasions on the component were found most frequently on the anterior portion of the component. The components were then characterized as conforming or non-conforming on the basis of the radius of curvature mismatch between the glenoid and the humeral head. Edge deformation and radiolucent lines were found to occur with significantly greater frequency in association with the conforming components. The authors concluded that increased conformity between the humeral head and the glenoid leads to edge wear and glenoid loosening.
Clinical
Techniques of Conventional Prosthetic Arthroplasty In a biomechanical and clinical study examining various techniques for takedown and repair of the subscapularis during total shoulder replacement, fifteen cadaveric shoulders were divided into three groups of five. The first group underwent lesser tuberosity osteotomy with single-row repair, the second group underwent lesser tuberosity osteotomy with double-row repair, and the final group underwent tenotomy and repair. The repairs were cyclically stressed at 180 N for 400 cycles and then were loaded to failure. On the basis of the ultimate strength, the osteotomized specimens with single and double-row repair had a significantly higher load to failure than the tenotomy specimens did (430, 466, and 252 N, respectively). Clinically, 100 consecutive patients who had undergone total shoulder replacement with lesser tuberosity osteotomy with a double-row repair were evaluated at twelve to twenty-four months of follow-up. The belly-press test was normal in eighty-six patients, the lift-off test was normal in seventy-nine patients, and eighty-two patients could tuck in their shirt. The authors concluded that osteotomy of the lesser tuberosity with a double-row repair improves subscapularis function after total shoulder replacement.
Outcomes of Arthroplasty
Constrained Prosthetic Arthroplasty The introduction of reverse total shoulder arthroplasty has provided us with another option for the treatment of shoulder pathology. However, the cost of this newly introduced technology is unknown to many. Collins performed a comparison of charges, costs, and hospital reimbursements for a consecutive series of twenty-eight reverse total shoulder arthroplasty procedures and a randomly selected group of twenty-eight standard total shoulder arthroplasties that were performed during the same time interval. The cumulative operating room charges for reverse total shoulder arthroplasty exceeded those for conventional total shoulder arthroplasty by $226,947.00. The average length of stay was 2.8 days for reverse total shoulder arthroplasty, compared with 2.0 days for total shoulder arthroplasty. The implant costs were $14,837.00 for reverse total shoulder arthroplasty, compared with $9327.00 for total shoulder arthroplasty. Actual reimbursement was $7479.00 for reverse total shoulder arthroplasty, compared with $7861.00 for total shoulder arthroplasty. With all costs considered, there was a net loss to the hospital of $7358.00 for reverse total shoulder arthroplasty as compared with $1466.00 for total shoulder arthroplasty. The authors concluded that although reverse total shoulder arthroplasty offers potentially excellent solutions to patients with rotator cuff-deficient arthritic shoulders, there is no profit margin and, with higher complication rates, the widespread use of this implant should be carefully considered.
Complications and Revisions
Fractures
Clavicular Fractures Potter and colleagues performed a review of thirty patients to determine if delay in the repair of displaced, midshaft clavicular fractures negatively affected shoulder strength or outcome. All patients had sustained a completely displaced, closed, midshaft clavicular fracture. Included in the review were fifteen patients who had undergone acute open reduction and internal fixation with a compression plate and fifteen patients who had undergone delayed reconstruction with open reduction and compression plate fixation for the treatment of nonunion or malunion at a mean of fifty-eight months after the injury. Functional assessment was performed with use of the DASH and Constant scores as well as objective muscle strength and endurance testing. There were no significant differences between the acute fixation group and the delayed reconstruction group with regard to range of motion. In a subset of each group that was tested for endurance, delayed fixation led to a significant decrease in muscle endurance with regard to shoulder flexion (p = 0.007). Late reconstruction of nonunion or malunion following a displaced midshaft fracture of the clavicle resulted in restoration of objective muscle strength similar to that seen in association with immediate fixation; however, there was a significant loss in muscle endurance as well as a trend toward a decrease in outcome scores (DASH and Constant scores).
Miscellaneous Mair reported on a case series of six patients who had previously undergone an arthroscopic SLAP (superior labrum anterior-to-posterior) lesion repair aided by a transtendinous portal. Each of these patients was found to have a substantial tear of the rotator cuff in the area of the transtendinous portal. The average age of the patients was 34.4 years. Five patients were noted to have a normal rotator cuff at the time of the index SLAP repair. The other patient was noted to have a mild partial supraspinatus tear. Five of the six patients reported that the symptoms were worse following the index SLAP repair. All patients underwent repeat shoulder arthros-copy at an average of fifteen months following the original SLAP repair. All patients were noted to have a full-thickness rotator cuff tear associated with the previous transtendinous portal. Following rotator cuff repair, the patients demonstrated significant improvement. The mean ASES score improved from 45.4 (range, 34 to 60) preoperatively to 90.5 (range, 77 to 100) at a mean of sixteen months of follow-up. The authors stressed placement of the portal medial to the muscle-tendon junction to avoid this complication. Chondrolysis is a rare but devastating complication of shoulder arthroscopy. Larsen and associates reported on six cases of severe chondrolysis following arthroscopy in a group of patients between fifteen and thirty-two years of age. Four of the six patients had previously been managed with thermal capsulorrhaphy, and all patients had had previous labral or instability surgery. The presenting complaint was severe pain and loss of motion that were not responsive to activity modification, medications, and physical therapy. Four patients underwent humeral head resurfacing (one with additional glenoid interposition), and two underwent hemiarthroplasty. Pain relief following the arthroplasty procedures was consistent, but function was highly variable. The majority of the cases were thought to be related to intraarticular use of thermal tissue ablators. However, some patients had development of chondrolysis with minimal or no use of thermal devices in the shoulder. The authors recommended the judicious use of thermal energy within the joint and noted that care should be taken not to allow the fluid temperature to rise during use of these devices. Hansen reported on 152 patients who underwent 177 shoulder arthroscopies between January 2003 and December 2005 for the treatment of postarthroscopic evidence of chondrolysis. Twelve shoulders in ten patients who underwent arthroscopic stabilization had development of chondrolysis. All of these patients had been managed postoperatively with an intra-articular pain pump catheter infusing Marcaine (0.25%) with epinephrine at a concentration of 1:200,000. Seven other patients who were managed with an intraarticular pain pump catheter did not have development of chondrolysis. No other patients had development of chondrolysis in this group. No other common factors were identified. The authors pointed out that the pH of marcaine with epinephrine is between 3.5 and 5.5. All cases of chondrolysis occurred after the beginning of the use of a larger pain pump that infused this medication at a rate of 4.16 mL/hour over two or three days. Although the exact etiology and mechanism of chondrolysis are still unknown, the authors believed there is a significant risk associated with the use of intraarticular pain pump catheters and bupivicaine with epinephrine. These pumps should be used with caution until the safety of constantly infusing local anesthetics intra-articularly is better defined.
Instability Basic Science Chebli and associates presented the results of a biomechanical evaluation of a novel lateral collateral ligament reconstruction technique involving the use of split anconeus fascia. In this technique, a strip of anconeus fascia is released from its origin and is split down to its insertion on the ulna. One segment is passed under the anular ligament to reconstruct the radial collateral ligament proper, and the inferior strip is used to reconstruct the lateral ulnar collateral ligament with use of a docking technique. Ten fresh-frozen cadaveric elbows had resection of the lateral collateral ligament followed by reconstruction with use of the split anconeus fascia. A pivot-shift test was performed, and ultimate load to failure was recorded and compared with that in ten intact elbows. The ultimate load to failure was 110.5 N in the reconstruction group, compared with 99.7 N in the control group. There was no significant difference between these two groups. This novel technique appears to have biomechanical support for its clinical use.
Clinical
Lateral Epicondylitis
Fractures and Dislocations
Humerus (Capitellum)
Radial Head The goal of the study by Herbertsson was to evaluate the long-term outcome of conservatively treated Mason type-II fractures of the radial head. Fifty-three patients with an average age of forty-seven years at the time of the injury were reevaluated at an average of nineteen years after the injury. The primary treatment included immediate mobilization in nine patients and plaster immobilization for an average of two weeks in forty-four. A delayed radial head excision was performed in eight patients. Forty-one patients (77%) had no subjective complaints at the time of follow-up, ten (19%) had occasional elbow pain, and two (4%) had pain additionally at rest. Flexion in the injured elbows was limited compared with that in the uninjured elbows (137° ± 6° compared with 139° ± 7°), as was extension (-4° ± 11° compared with 1° ± 5°) and supination (85° ± 8° compared with 88° ± 4°) (p < 0.01 for all). The formerly injured elbows had significantly more cysts, sclerosis, and osteophytes than did the un-injured elbows (p < 0.001). On the basis of that study, we can conclude that most individuals with a Mason type-II fracture of the radial head have a good long-term outcome following conservative treatment. Ring investigated the long-term results of open reduction and internal fixation of slightly displaced, but stable, partial articular (Mason type-II) fractures of the radial head. Sixteen patients were evaluated at an average of twenty-two years. Eleven patients were managed with screw fixation, whereas the remaining five underwent fixation with a small T-plate. Complications occurred in five patients and included two deep infections, two cases in which hardware restricted motion, and one posterior interosseous nerve palsy. The average flexion-extension arc at the time of the latest follow-up was 129°. Results were mixed, with thirteen of sixteen patients having a good or excellent result according to the MEPS. The authors concluded that the results were no better than the reported results of nonoperative treatment for these minimally displaced, uncomplicated fractures.
Complex Instability
Arthritis Mallon and colleagues retrospectively reviewed forty patients with forty-one semiconstrained total elbow replacements who had at least ten years of follow-up. The preoperative diagnoses were posttraumatic arthritis (twenty-four patients), inflammatory arthritis (twelve patients), osteoarthritis (four patients), and post-tumor resection (one patient). Patient selection was limited to those willing to adopt a sedentary lifestyle. The average MEPS improved from 36 preoperatively to 90 postoperatively. The patients had a high (100%) self-reported rate of satisfaction, despite a 34% rate of complications. Thirteen elbows required revision, which resulted in an average duration of survival of eighteen years for the elbow replacement. On the basis of those findings, we can conclude that the adoption of a sedentary lifestyle results in long-term component survival for semiconstrained elbow replacements.
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 cited already in this Update, nine level-I articles were identified that were relevant to shoulder and elbow surgery. A list of those titles is appended to this review. 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.
Shoulder Tan CK, Guisasola I, Machani B, Kemp G, Sinopidis C, Brownson P, Frostick S. Arthroscopic stabilization of the shoulder: a prospective randomized study of absorbable versus nonabsorbable suture anchors. Arthroscopy. 2006;22:716-20. This study prospectively evaluated patients undergoing arthroscopic Bankart repair who were randomized to either a nonabsorbable suture anchor group or an absorbable suture anchor group. One hundred and thirty patients with recurrent traumatic anterior instability of the shoulder were included in the study. Six patients were lost to follow-up. Patients were assessed preoperatively and postoperatively on the basis of the Oxford Instability Score, a visual analog scale for pain and instability (VAS Pain and VAS Instability), and a quality-of-life questionnaire (SF-12). The average duration of follow-up was 2.6 years. No differences between the groups were noted in terms of the rate of recurrence or any of the scores. Recurrent dislocation occurred in four patients in the nonabsorbable suture anchor group and three patients in the absorbable suture anchor group, for an overall redislocation rate of 6% in the whole series. No differences in the outcome of arthroscopic Bankart repair were seen between the two groups. Boehm TD, Werner A, Radtke S, Mueller T, Kirschner S, Gohlke F. The effect of suture materials and techniques on the outcome of repair of the rotator cuff: a prospective, randomised study. J Bone Joint Surg Br. 2005;87:819-23. This prospective, randomized study on the repair of rotator cuff tears compared the clinical results of two suture techniques for which different suture materials were used. One hundred patients with tears of the rotator cuff were prospectively randomized into two groups. Group 1 underwent transosseous repair with number-3 Ethibond with use of modified Mason-Allen sutures, and Group 2 underwent transosseous repair with 1.0-mm polydioxanone cord with use of modified Kessler sutures. After twenty-four to thirty months, the patients were evaluated clinically on the basis of the Constant score and with use of ultrasonography. Ninety-two patients completed the study. No significant difference was seen between the two groups in terms of the Constant score (91% compared with 92%), the rate of further tearing (18% compared with 22%), or the rate of revision (4% compared with 4%). In cases of further tearing, the outcome in Group 2 did not differ from that for the intact repairs (91% compared with 91%), but in Group 1 it was significantly worse (94% compared with 77%; p = 0.005). Iannotti JP, Ciccone J, Buss DD, Visotsky JL, Mascha E, Cotman K, Rawool NM. Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears. J Bone Joint Surg Am. 2005;87:1305-11. Ninety-eight patients (ninety-nine shoulders) with a diagnosis of a rotator-cuff-related problem underwent office-based ultrasonography of the shoulder. The results of the ultrasonographic studies were compared with the results of magnetic resonance imaging and the operative findings. Office-based ultrasonography led to the correct diagnosis for thirty-seven (88%) of forty-two shoulders with a full-thickness rotator cuff tear, twenty-six (70%) of thirty-seven shoulders with a partial-thickness rotator cuff tear, and sixteen (80%) of twenty shoulders with normal tendons. In no case was the surgical approach altered by the operative findings, but the operative finding of a full-thickness tear resulted in an arthroscopic rotator cuff repair in four shoulders. There were no significant differences between magnetic resonance imaging and ultrasonography with regard to the correct identification of a full-thickness tear or its size. The sensitivity of ultrasonography for detecting the anteroposterior tear size was 86%, and that of magnetic resonance imaging was 93% (p = 0.26). The sensitivity of ultrasonography for detecting the mediolateral tear dimension was 83%, and that of magnetic resonance imaging was 88% (p = 0.41). A well-trained office staff and an experienced orthopaedic surgeon can effectively utilize ultrasonography, in conjunction with clinical examination, to accurately diagnose the extent of rotator cuff tears. Lo IK, Litchfield RB, Griffin S, Faber K, Patterson SD, Kirkley A. Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial. J Bone Joint Surg Am. 2005;87:2178-85. Forty-two patients with a diagnosis of osteoarthritis of the shoulder were randomized to receive a hemiarthroplasty or a total shoulder arthroplasty. The patients were evaluated preoperatively and postoperatively with a disease-specific quality-of-life measurement tool (the Western Ontario Osteoarthritis of the Shoulder [WOOS] index), general shoulder-rating scales (the University of California at Los Angeles [UCLA] shoulder scale, the Constant score, and the American Shoulder and Elbow Surgeons [ASES] evaluation form), general pain scales (the McGill pain score and visual analog scale), and a global health measure (the Short Form-36 [SF-36]). Significant improvements in disease-specific quality of life were seen two years after both total shoulder arthroplasty and hemiarthroplasty. There were no significant differences in quality of life (WOOS score) between the group managed with total shoulder arthroplasty and that managed with hemiarthroplasty (p = 0.18). Both total shoulder arthroplasty and hemiarthroplasty improved disease-specific and general quality-of-life measurements. Sabeti-Aschraf M, Dorotka R, Goll A, Trieb K. Extracorporeal shock wave therapy in the treatment of calcific tendinitis of the rotator cuff. Am J Sports Med. 2005;33:1365-8. A prospective, randomized study of fifty patients was performed. The population was divided into two groups (the navigation group and the feedback group). In the navigation group, the calcium deposit was localized with use of a radiographically guided, three-dimensional, computer-assisted device. The feedback group was treated after the point of maximum tenderness was located through palpation by the therapist with use of feedback from the patient. A total of three sessions of constant low-energy focused shock wave therapy was administered in weekly intervals in both groups. Both groups had significant improvements in the Constant and Murley score and the visual analog pain scale after twelve weeks. The results in the navigation group were significantly better than those in the feedback group. In the navigation group six calcium deposits disappeared and nine were altered, whereas in the feedback group one deposit disappeared and twelve were altered. No severe complications occurred. Three-dimensional, computer-assisted navigation yields significantly better results and is therefore recommended when extracorpo-real shock wave therapy is used for the treatment of calcific tendinitis of the rotator cuff.
Elbow The effect of a new dynamic extensor brace on the symptoms of lateral epicondylitis was assessed. Sixty-three patients were randomly assigned to twelve weeks of brace treatment (Group 1, thirty patients) or no brace treatment (Group 2, thirty-three patients). Outcome measures included pain (as assessed with a visual analog scale), pain-free grip strength, maximum grip strength, and functionality of the arm. Brace treatment resulted in significant pain reduction, improved functionality of the arm, and improvement in pain-free grip strength. The beneficial effects of the dynamic extensor brace observed after twelve weeks were significantly different from the effects in the group that received no brace. The beneficial effects of the brace were sustained for another twelve weeks. No correlation between the duration of symptoms and treatment effects of the brace was revealed. Buchbinder R, Green SE, Youd JM, Assendelft WJJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database of Systematic Reviews. 2005;4. This review included nine trials that randomized 1006 patients to extracorporeal shock wave therapy or placebo and one trial that randomized ninety-three patients to extracorporeal shock wave therapy or steroid injection. The quality of the study methodology was determined, and the data were assessed. When possible, pooled analysis was performed. If there was too much heterogeneity of the data, no pooling was performed. On the basis of the review of the placebo-controlled trials involving 1006 patients, there was a "platinum" level of evidence suggesting that extracorporeal shock wave therapy provides little or no relief of pain or improvement in function as compared with placebo. There was also a "silver" level of evidence that steroid injection may be more effective than extracorporeal shock wave therapy. Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005;87:1297-304. One hundred and fourteen patients with a minimum six-month history of lateral epicondylitis that had been unresponsive to conventional therapy were randomized into active treatment and placebo groups. The protocol consisted of three weekly treatments of either low-dose shock wave therapy or a sham treatment. Sixty-one patients completed one year of follow-up, whereas thirty-four patients crossed over to receive active treatment. A significant difference in pain reduction was observed at twelve weeks in the intent-to-treat cohort (p = 0.001), with an improvement in the pain score of at least 50% being seen in thirty-four of the fifty-six patients in the active treatment group who were managed according to protocol as compared with only seventeen of the fifty-eight subjects in the placebo group. This improvement persisted in those who were followed to one year. Functional activity scores, activity-specific evaluation, and the overall impression of the disease state all showed significant improvement as well (p < 0.05). Crossover patients also showed significant improvement after twelve weeks of active treatment, with 56% (nineteen) of thirty-four achieving at least a 50% improvement in the pain score (p < 0.0001). Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg [Br]. 2005;30:521-4. Sixty-six patients with pain and/or neurological deficits with clinically and electromyographically proven cubital tunnel syndrome were prospectively randomized into two treatment groups. Thirty-two patients underwent ulnar nerve decompression without transposition, and thirty-four underwent anterior subcutaneous transposition of the nerve. Follow-up examinations evaluating pain, motor and sensory deficits, and motor nerve-conduction velocities were performed three and nine months postoperatively. There were no significant differences between the two groups with regard to the outcome at either postoperative follow-up examination. Thus, the authors recommended simple decompression of the nerve for patients without deformity of the elbow.
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Introduction
Shoulder
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