Average Constant Score Research Articles

Comparison of Repair Integrity and Functional Outcomes for 3 Arthroscopic Suture Bridge Rotator Cuff Repair Techniques

Background: No reported study has compared the clinical outcomes of suture bridge techniques. Purpose: To compare the functional outcomes and repair integrity of the arthroscopic single-mattress (SM), double-pulley (DP), and double-mattress (DM) suture bridge (SB) techniques for full-thickness rotator cuff tears. Study Design: Cohort study; Level of evidence, 2. Methods: Seventy-eight consecutive shoulders with full-thickness rotator cuff tears and a 1- to 4-cm anteroposterior dimension underwent arthroscopic SB repairs. The SM-SB technique was used in the first 26 consecutive shoulders, the DP-SB method was used in the second 26 consecutive shoulders, and the DM-SB repair was used in the final 26 consecutive shoulders. Seventy-four shoulders (94.9%) underwent postoperative evaluation for cuff integrity using MRI or ultrasound. Clinical outcomes were evaluated in 76 shoulders (97.4%) at a minimum of 2 years postoperatively. Clinical outcomes were evaluated using the shoulder rating scale of the University of California, Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES), and Constant scores at an average of 31 months postoperatively. Results: At final follow-up, the average ASES, UCLA, and Constant scores improved significantly: respective scores were 88.46, 30.58, and 73.96 in the SM-SB group (P < .001); 87.19, 31.35, and 72.50 in the DP-SB group (P < .001); and 87.19, 32.81, and 75.35 in the DM-SB group (P < .001). However, there were no significant differences among the 3 groups in terms of the ASES, UCLA, or Constant scores (P = .954, .210, and .755, respectively). The retear rate of repaired rotator cuffs was 20% in the SM-SB group, 12.5% in the DP-SB group, and 12% in the DM-SB group; however, the differences among the 3 groups were not statistically significant (P = .674). The number of suture anchors (mean ± SD) used for repair was 4.31 ± 0.47 in the SM-SB group, 4.00 ± 0.00 in the DP-SB group, and 3.38 ± 0.50 in the DM-SB group (P < .001). Conclusion: Arthroscopic rotator cuff repair yielded successful functional outcomes without significant differences among the 3 SB techniques. Additionally, no significant differences in repair integrity were observed among the 3 methods postoperatively.

Post-traumatic acromioclavicular instability reconstruction with coracoacromial ligament and conjoined tendon: A preliminary report

BackgroundMany surgical techniques have been proposed to treat acromioclavicular (AC) injuries; however, anatomic coracoclavicular (CC) reconstructions with local tissue grafts have not been reported in previous studies. The aim of this study was to investigate early outcomes of this innovative technique. MethodsBetween 2004 and 2011, 15 patients with post-traumatic AC instability underwent anatomic reconstructions by two surgeons at our institution. Nine patients were treated with local tissue grafts, and these included six patients who underwent double-bundle reconstructions and three who underwent single-bundle reconstructions. The remaining six patients were treated with free tendon grafts. The clinical outcomes of the Constant scores and the radiographic results of the CC distance were further analyzed. ResultsIn patients who underwent reconstructions with local tissue grafts, those treated with double-bundle and selective-bundle reconstructions had an average postoperative Constant score of 89.0 ± 11.5 and 71.7 ± 38.4, respectively. In patients who underwent reconstructions with free tendon grafts, the average score was 73.0 ± 29.4. There was no statistically significant difference among the three reconstruction procedures. Only one patient showed residual AC separation on plain-film radiography. ConclusionThis innovative technique provided clinical and radiographic results that were comparable to those achieved with free tendon grafts. This procedure can be an alternative surgical option for treating AC joint instability.

Four-part fracture dislocations of the proximal humerus in young adults: Results of fixation

IntroductionFour-part fracture dislocations of the proximal humerus occurring in young age are extremely difficult fractures with a high incidence of complications. The risk of avascular necrosis is high; hence, prosthetic replacement is the treatment of choice in older patients with these complex fractures; on the other hand, the longevity of the prosthesis is the main concern in young age. Thus, every effort should be made to fix these fractures in the young. The purpose of this study is to evaluate the results of fixation in a series of young patients with four-part fracture dislocations; to support the trend to fix these fractures; and reserve prosthetic replacement to older patients. MethodsIn a prospective study, 39 patients younger than 40 years of age with four-part fracture dislocations were treated with open reduction and fixation either with K-wires or with a proximal humerus plate. Ethibond sutures were used in all patients to supplement fixation of tuberosities. In 18 patients, the dislocation was anterior and in 21 patients it was posterior. Twelve patients had an anatomic neck fracture and 27 had a surgical neck fracture. Surgery was performed within 1 week after the injury. Physiotherapy was initiated according to the general condition of the patient and the stability of fixation; the average time was 5 days after surgery. ResultsPatients were followed up for an average of 26 months. Union was achieved in 36 patients and three patients had nonunion, all in anatomic neck fractures. Avascular necrosis developed in eight patients, seven of which were fractures of the anatomic neck and one was in the surgical neck. The average Constant score was 77; 26 patients were pain free, nine had mild pain and four had moderate pain. The mean active anterior elevation was 145°. Patients were divided into two groups based on the anatomic configuration of the fracture; in 12 patients (group 1), the head was fractured at the anatomical neck and in 27 patients (group 2), the head was fractured at the surgical neck. In group 2, the active anterior elevation was significantly better and the Constant score was higher. ConclusionsAnatomical reduction and rigid fixation with meticulous surgical technique can lead to satisfactory results. The results in surgical neck fractures are superior to anatomic neck fractures with significantly less complications.

Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate

The purpose of this study was to evaluate the effectiveness and complications of the locking proximal humerus plate to treat proximal humerus fractures. A retrospective clinical trial. Department of Orthopaedics, Tianjin Medical University General Hospital. Sixty-eight consecutive patients with three- or four-part fractures of the proximal humerus were treated with locking proximal humerus plates. The deltopectoral anterolateral acromial approach was used to the proximal humerus; open reduction and locking proximal humerus plate were applied. Constant Score was used to measure the shoulder functional recovery, and Visual Analog Scale (VAS) was used to measure subjective evaluation of pain. The radiology was observed. After average 26.7months, the average Constant Score was 72.6±13.2 points and the average VAS was 1.2±0.8 points. All the complications such as screw perforation into the glenohumeral joint, screws loosening, soft tissue infections, avascular necrosis and delayed union occurred in eight cases (11.8%). The effectiveness of the locking proximal humerus plate was similar to other published literatures on treating fractures of the proximal humerus; however, a lower complications rate in short follow-up time was observed in this study. It may potentially provide a favorable option for treating three- or four-part fractures of the proximal humerus. Dealing with each particular fracture pattern, surgeons should have a decision of appropriate way to internal fixation.

Operative Fixation of Displaced Middle Third Clavicle (Edinburg Type 2) Fracture with Superior Reconstruction Plate Osteosynthesis

Conservative management of middle third clavicle fracture has been recently reported with suboptimal outcomes. Despite higher nonunion rates in initial open reduction and internal fixation, understanding the problem better and taking in accounts of previous shortcomings, such fractures can be optimally treated by open reduction and internal fixation with reconstruction plate. To study the outcome of middle third clavicle fracture treated with superior reconstruction plating in terms of function using Constant shoulder score, union time and rate, complications and patient satisfaction. Twenty patients with displaced middle third clavicle fracture (Edinburg type 2) treated with open reduction and internal fixation with reconstruction plate implanted in superior surface were prospectively followed for at least one year after surgery. There were 20 patients, 16 males and 4 females. The mean age of the patients was 31.5 years with SD 11.5 years (range 15-60 years) and 5 patients (25%) had associated injuries. All fractures united in 16 weeks or less in near anatomic position with complication in 2 (5%) patients, one deep infection and one frozen shoulder which on subsequent management recovered well. There was no nonunion or implant failure. The average Constant score was 97.45 in one year follow up and the patients were relatively satisfied with the treatment.The most common indication (25%) for hardware removal was young age of the patient, hardware prominence and occasional discomfort. This small series shows that displaced midshaft clavicle fracture can be optimally treated with operative fixation implanting the reonstruction plate in superior surface with six cortical purchases on either side and supervised physiotherapy, although subsequent surgery for implant removal might be necessary.

Arthroscopically assisted internal fixation of the symptomatic unstable os acromiale with absorbable screws

Symptomatic meso- type os acromiale is a common pathology with inconsistent outcomes of treatment with various surgical techniques. We report the outcome of a new technique for arthroscopic fusion of symptomatic os acromiale with absorbable screws. The study included 8 shoulders in 8 patients with symptomatic meso- type os acromiale who were treated with the use of a new technique for arthroscopic fusion with absorbable screws. The mean age was 54 years (range, 38-67 years), and the mean time from onset of symptoms to surgery was 18 months (range, 9-25 months). No patients reported a specific traumatic event before the onset of symptoms, and all noted the insidious onset of pain with no precipitating event. The average length of follow-up was 22 months (range, 12-36 month). The average Constant score improved from 49 points (range, 35-57 points) to 81 points (range, 75-86 points). The average satisfaction score improved from 4.5 of 10 (range, 2-6) to 8.5 of 10 (range 7-9). All patients made a good clinical recovery at 3 to 6 months after surgery. At the last follow-up, full radiographic union was observed in 6 patients, partial union in 1 patient, and persistent radiologic nonunion in 1 patient. Anterior bulging of the absorbable screws was noted in 2 patients, and the screws were trimmed 6 months after the first procedure. We have found that this new arthroscopic technique of fixation of os acromiale with absorbable screws provides promising clinical, cosmetic, and radiologic results with high patient satisfaction.

Midterm outcome after rotator cuff reconstruction

Rotator cuff tear is a common degenerative shoulder disorder that often requires surgical treatment. However, the correlation between the size of the tear and the functional results is somewhat controversial, which generates inconsistency among orthopaedic surgeons about the indications for and methods of rotator cuff reconstruction. The aim of the authors was to evaluate the midterm functional outcome after rotator cuff reconstruction and the possible connection between the results and the surgical technique or the postoperative ultrasound examination. In addition, recently published corresponding studies are also reviewed by the authors. Twenty-seven patients with full thickness rotator cuff tear were enrolled into the study who were treated either by arthroscopic (14 patients) or by open repair (13 patients) technique. Functional results were assessed using clinical tests. Ultrasound examination was also performed. The average postoperative Constant Score was 73, the average DASH (Disabilities of the arm, shoulder and hand score) was 14. The Constant scores averaged 80 for the arthroscopic and 70 for the open group. Ultrasound examination showed partial or full thickness retear of the cuff in 40% of the cases. More than 70% of the patients had excellent or good results two years after the reconstruction. The change in the acromiohumeral distance or partial retear failed to affect the results significantly, but full thickness tear had an effect on them.

Arthroscopic Pancapsular Plication for Multidirectional Shoulder Instability in Overhead Athletes

Treating shoulder multidirectional instability with an open stabilization procedure has been reported to have good results. However, few studies exist of arthroscopic plication, especially in overhead athletes. The purpose of this study was to evaluate the clinical outcomes of arthroscopic pancapsular plication for multidirectional instability in overhead athletes.Twenty-three athletes with symptomatic multidirectional instability were treated with arthroscopic pancapsular plication and evaluated at a mean follow-up of 36.3 months (range, 24-61 months). Mean patient age was 23.3 years (range, 19-33 years). Functional outcomes were evaluated with the American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder score, and Rowe instability score. The degree of pain and range of motion were also recorded. All postoperative functional scores were rated good to excellent, with an average ASES score of 88.4 (range, 82-95), average Constant shoulder score of 88.1 (range, 81-100), and average Rowe instability score of 86.7 (range, 80-100). Five patients returned to the same level of competitive sports, and 18 returned to a limited level. All patients were satisfied with the stability postoperatively. No significant change was observed in postoperative range of motion, but patients who returned to a limited level of sports had lower functional scores and more pain than did those who fully returned to sports.Arthroscopic pancapsular plication for treating multidirectional instability in overhead athletes can provide good stability. However, the low rate of return to a full level of overhead sports is a problem. Further evaluation of the benefits of this procedure for overhead athletes with symptomatic multidirectional instability is needed.

Modified tension band for displaced type 2 lateral end clavicle fractures

Displaced type 2 lateral end clavicle fractures have a tendency to delayed union or non-union. Various methods of stabilisation of the displaced lateral end fractures are described. The increasing use of implants to fix such fractures also necessitates extensive dissection for implant retrieval. Adequate reduction and minimal tissue trauma during implant placement and removal would be ideal modalities for fixation of such fractures. All displaced type 2 lateral end clavicle fractures fulfilling our inclusion criteria were reduced with a small anterosuperior incision. Anteroposterior drill holes were made in both the fragments and a nonabsorabable polyester suture was passed through. The fracture was reduced and fixed with transacromial smooth Kirshner wires. The suture was tied with the knot superiorly in a figure-eight manner. The arm was supported in an arm pouch for sixweeks. The Kirshner wire was routinely removed after sixweeks in an out-patient department. Clinico-radiological outcome was studied at six weeks, and monthly intervals thereafter until union. All 16 fractures united. The mean average age of patients was 36.25years with a SD of 11.35. There was no loss of reduction even after removal of Kirshner wires at sixweeks. The mean average time of union was 10.75weeks with a SD of 3.92. All patients regained near normal range of motion, and the mean average constant score at the end of one year was 98.37 with a SD of 2.87. All patients returned to preinjury level by the one-year follow-up. The range of motion remained the same in those who were followed up in successive years. Skin impingement with bent Kirshner wires were noted in four cases. Kirshner wires backed out in one case before sixweeks but there was no loss of reduction. Infection and Kirshner wire breakage were not noted in our series. The clinico-radiological outcomes with our modified tension band fixation for displaced type 2 lateral end clavicle fractures were encouraging and comparable with earlier studies.

Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon’s experience?

The goal of this study was to compare 2 consecutive series of 240 reverse total shoulder arthroplasties (TSA) in order to evaluate if the increase in surgeon experience modified the indications, clinical and radiographic results, and rate of complications. Two hundred forty reverse TSA performed between July 2003 and March 2007 were clinically and radiographically evaluated by an independent examiner with a minimum follow-up of 2 years and compared with a previous published study (240 cases implanted by the same 2 surgeons between May 1995 and June 2003). The main etiology remained cuff tear arthropathy with an increase noted between the 2 studies. The rate of revision arthroplasty as an etiology decreased from 22.5% to 9.1%. Conversely, the rate of rheumatoid arthritis increased from 0.4% to 6.3%. The average postoperative Constant score was significantly better than the first series (66.9 vs 59.7, P < .001). The postoperative complication rate decreased with increased experience (from 19% to 10.8%), with dislocations reducing (from 7% to 3.2%), and infections reducing (from 4% to 0.9%). However, the number of nerve palsies increased. The revision rate decreased from 7.5% to 5%. The rate of glenoid notching remained stable, but the severity of notching decreased. Experience did not lead us to operate on younger patients, but significantly modified patient selection, results, and complications. Increased experience with the reverse shoulder arthroplasty did not reduce the rate of glenoid notching.

Suture fixation versus cable cerclage of the tuberosities in shoulder arthroplasty-clinical and radiologic results

The most important individual parameter linked to functional outcome following hemiarthroplasty for fractures of the proximal humerus is anatomical healing of the tuberosities. The aim of our study was to evaluate whether the fixation method influences tuberosity healing and functional outcome. Twenty-five consecutive patients with acute 4-part fractures of the proximal humerus were treated with hemiarthroplasty and cable fixation of the tuberosities. Twenty-nine previous patients with four-part fractures treated with hemiarthroplasty and suture fixation of the tuberosities were included as a control group. Functional evaluation was measured with the Constant Score 1 year after the operation. Radiographic evaluation included evaluation of the extent of tuberosity healing and head centralisation. The average Constant Score was 53.2 points in the suture group and 60.9 in the cable group (p = 0.29). An x-ray evaluation revealed that 40% of the tuberosities in the suture group were anatomically healed versus 75% (p = 0.027) in the cable group. In the suture group, 44% of the prostheses showed marked superior migration, whereas 25% of the prostheses in the cable group showed such migration (p = 0.027). In our collective adding an encircling steel cable for the fixation of the tuberosities resulted in higher anatomical healing rates.

Treatment of Traumatic Anterior Shoulder Dislocation in Patients Older Than 60 Years

Background: The prevalence of traumatic anterior shoulder dislocation in the elderly population has increased; however, no consensus has been reached regarding the management of shoulder dislocations in elderly patients. Purpose: This study investigated the clinical manifestations of traumatic anterior shoulder dislocation in patients older than 60 years and evaluated the functional outcomes of different treatment modalities based on associated abnormalities and the number of dislocations. Study Design: Case series; Level of evidence, 4. Methods: Sixty-seven patients older than 60 at the time of primary shoulder dislocation were included. Magnetic resonance imaging or ultrasonography was performed on all patients to confirm associated injuries. Fifty-two patients were treated for primary shoulder dislocation and 15 for recurrent dislocation. Results: Postinjury examinations revealed no associated injuries in 31 patients with primary shoulder dislocation; these patients recovered shoulder function after rehabilitation (American Shoulder and Elbow Surgeons [ASES] score: 93 ± 6; Constant score: 89 ± 8). For the other 36 patients, 33 were found to have rotator cuff tears (isolated cuff tears in 16), and 3 were found to have an isolated Bankart lesion. The average ASES score of the 17 patients with primary shoulder dislocation who were treated operatively was 83 ± 10, and the average Constant score was 78 ± 13 at final follow-up. The average ASES score of patients with recurrent shoulder dislocation was 89 ± 9, and the average Constant score was 84 ± 13. No statistically significant differences in functional shoulder outcomes between patients with primary and recurrent dislocation were evident (P > .05). However, patients who were treated nonoperatively showed significantly better recovery of shoulder function than patients who were treated operatively regardless of the number of dislocations (P < .001). No recurrent shoulder dislocation was observed in any patient during an average follow-up period of 55 months. Conclusion: The accurate diagnosis of associated injuries after traumatic anterior shoulder dislocation in patients older than 60 is critical for the recovery of shoulder function because more than half of patients had rotator cuff tears or anterior capsulolabral lesions, which may lead to recurrent shoulder dislocation. Satisfactory clinical outcomes without recurrence were obtained after early detection of abnormalities and different treatment modalities based on associated injuries and the number of dislocations experienced.

Evaluation of Arthroscopic Stabilization of Acute Acromioclavicular Joint Dislocation Using the TightRope System

The purpose of this study was to evaluate the results of the arthroscopic treatment of acute acromioclavicular dislocation using the TightRope system (Arthrex, Naples, Florida). Between January 2006 and May 2007, ten shoulders in 10 patients with acute acromioclavicular joint dislocation (Rockwood types IV and V) underwent arthroscopic acromioclavicular joint stabilization using the TightRope. Average patient age was 30 years (range, 22-42 years), and mean follow-up was 24 months (range, 18-30 months). Follow-up occurred at 2 and 6 weeks, 3 months, and then every 6 months postoperatively. The shoulders were evaluated radiologically by comparing the acromioclavicular joint with the normal side and clinically by assessing the pain, function, and range of joint motion using the Constant score.Ten patients returned to work without pain 10 to 12 weeks postoperatively. Average Constant score was 96.3 (range, 94-99) at last follow-up. Because of technical error, 1 patient experienced TightRope fixation failure on the coracoid side, and the acromioclavicular joint was redislocated, which was treated by an open technique. The 10 patients were satisfied with their functional results and cosmetic appearance.The arthroscopic treatment of acute acromioclavicular dislocation using the TightRope is a minimally invasive surgical technique that has been proven effective for the treatment of these lesions. It is characterized by less morbidity, less hospitalization, excellent cosmoses, and early rehabilitation.

Minimally Invasive Polyaxial Locking Plate Fixation of Proximal Humeral Fractures: A Prospective Study

The surgical treatment for displaced humeral head fractures overlooks a broad variety of surgical techniques and implant systems. A standard operative procedure has not yet been established. In this article, we report our experience with a second-generation locking plate for the humeral head fracture that is applied in a standardized nine-step minimally invasive surgical technique (MIS). In a prospective study from May 2008 until November 2009, a cohort of 79 patients with 80 proximal humerus fractures were operated in a MIS procedure using a polyaxial locking plate. Follow-up examination at 6 weeks and 6 months postoperative included radiologic examinations and a clinical outcome analysis by the Constant Score, the Visual Analog Scale for pain, and the Daily Activity Score. The mean patient age was 65.5 years ± 19 years. According to the Neer classification, there were 18 (22.5%) two-part (Neer III), 48 (60%) three-part (Neer IV), and 14 (17.5%) four-part fractures (Neer IV/V). The operation time averaged 65.6 minutes ± 27 minutes. In 13 patients (16.3%), revision was necessary because of procedure-related complications. After 6 months, the Visual Analog Scale for pain was 2.7 ± 1.6 and the Daily Activity Score showed 19.6 ± 6 points. The average age-related Constant Score after 6 months was 67.5 ± 24 points. MIS surgery of displaced humeral head fractures can be performed in all types of humeral head fractures leading to low complication rates and good clinical outcome. A standardized stepwise procedure in fracture reduction and fixation is recommended to achieve reliable good results.

Repair Integrity and Functional Outcome After Arthroscopic Rotator Cuff Repair

Background: Only a few studies have examined repair integrity and functional outcome after arthroscopic suture-bridge rotator cuff repair procedure. In addition, no reported study has compared outcomes between the suture-bridge and double-row techniques. Purpose: This study compared the functional outcome and repair integrity of arthroscopic double-row and conventional suture-bridge repair in full-thickness rotator cuff tears. Study Design: Cohort study; Level of evidence, 2. Methods: Fifty-two consecutive full-thickness rotator cuff tears with 1 to 4 cm of anterior to posterior dimension that underwent arthroscopic rotator cuff repair were included. A double-row technique was used in the first 26 consecutive shoulders, and a conventional suture-bridge technique was used in the next 26 consecutive shoulders. Fifty shoulders (92.5%) underwent magnetic resonance imaging or ultrasonography postoperatively. Clinical outcomes were evaluated a minimum 2 years (mean, 37.2 months; range, 24-54) postoperatively using the University of California at Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES), and Constant scores. The postoperative cuff integrity was evaluated a mean of 33.0 (range, 10-54) months postoperatively. Results: At the final follow-up, the average UCLA, ASES, and Constant scores improved significantly, to 32.3, 90.5, and 80.7, respectively, in the double-row group and to 30.6, 88.5, and 74.0, respectively, in the suture-bridge group. The UCLA, ASES, and Constant scores improved in both groups postoperatively (all P < .001); however, there was no significant difference between the 2 groups at final follow-up (P = .185, .585, and .053, respectively). The retear rate was 24% in the shoulders that underwent double-row repair and 20% in the shoulders that underwent suture-bridge repair; this difference was not statistically significant (P = .733). Conclusion: The arthroscopic conventional suture-bridge technique resulted in comparable patient satisfaction, functional outcome, and rates of retear compared with the arthroscopic double-row technique in full-thickness rotator cuff tears.

Glenoid loosening and failure in anatomical total shoulder arthroplasty: is revision with a reverse shoulder arthroplasty a reliable option?

Our purpose was to evaluate if, in case of aseptic glenoid loosening and failure in anatomical total shoulder arthroplasty (TSA), revision by a reverse shoulder arthroplasty (RSA) is a reliable therapeutic option. Retrospective multicenter cohort study of 37 consecutive anatomical TSA revised by RSA for aseptic glenoid loosening or failure. The decision to implant a RSA was related to the presence of associated complications: rotator cuff tears (n = 24), subscapularis insufficiency (n = 29), prosthetic instability (n = 13), and glenoid bone deficiency (n = 37). The patients were reviewed clinically and radiographically at a mean follow-up of 47 months (range, 24-104). Eighty-six percent of the patients were satisfied or very satisfied. The average Constant score increased from 24 to 55 pts (P < .0001) and active anterior elevation from 68° to 121° (P < .0001). Twenty-two of the 29 (76%) associated bone grafts were incorporated in the glenoid. Eight patients (21%) needed a subsequent reoperation because of recurrent or new complications: glenoid loosening (n = 3), prosthetic anterior instability (n = 3), and humeral subsidence (n = 2); the reverse prosthesis had to be converted to a hemiarthroplasty in 1 patient and removed in another. Revision with a RSA is a reliable therapeutic option which provides the double benefit of glenoid bone stock reconstruction by fixing the bone graft with the help of the baseplate and screws and of solving the problem of soft tissue insufficiency and prosthetic instability. However, surgeons should be aware that the rate of postoperative complications and subsequent reoperations is high, and that the surgical technique is demanding.

Combined tears of the subscapularis and supraspinatus tendon: clinical outcome, rotator cuff strength and structural integrity following open repair

Anterosuperior rotator cuff tears involving the subscapularis and supraspinatus tendons are less common than other tears of the rotator cuff. The purpose of this study was to report the clinical outcome, rotator cuff strength and structural integrity of open repair of combined anterosuperior rotator cuff tears. Forty-eight patients at an average age of 58 years underwent open repair of a combined supraspinatus and subscapularis tendon tear. The follow-up evaluation included clinical scores, rotator cuff strength testing with a custom-made force measurement plate (FMP) and postoperative MRI to evaluate repair integrity and muscle cross-sectional area. After a mean follow-up of 49 months the average Constant score improved from 43 points preoperatively to 79 points postoperatively. The SST and the pain VAS were significantly improved by the procedure (each <0.05). The combined tear group with partial subscapularis tears (G1) did not achieve significantly better score results than the combined tear group with a full-thickness subscapularis tear (G2) (p > 0.05). Strength for all rotator cuff components was reduced significantly (p < 0.05) compared with the contralateral shoulder in both groups. MRI revealed a retear-rate of 4% for the subscapularis and a retear-rate of 19% for the supraspinatus. Postoperative muscle cross-sectional area of all rotator cuff muscles did not differ significantly between G1 and G2 (p > 0.05). Open repair of combined anterosuperior rotator cuff tears achieved good postoperative results despite a residual rotator cuff strength deficit. Combined supraspinatus-/full-thickness subscapularis tears achieved equal clinical and radiographic results compared with supraspinatus-/partial-thickness subscapularis tears.

Nonoperative Treatment of Proximal Humerus Fractures: A Systematic Review

Proximal humerus fractures are common in the setting of osteopenia and osteoporosis and can often be treated nonoperatively. There are few studies that evaluate the long-term outcomes of nonoperative treatment of these fractures. We performed a systematic review of the literature to examine the results of nonoperative treatment of proximal humerus fractures. The PubMed search engine and EMBASE database were used. Inclusion criteria were: 1) proximal humerus fractures resulting from trauma; 2) age older than 18 years; 3) more than 15 patients in the study; 4) greater than 1 year follow-up; 5) at least one relevant functional outcome score; and 6) a quality outcome score of at least a 5 of 10 according to previously published scoring system. We identified 12 studies that included 650 patients with a mean age of 65.0 years (range, 51-75 years) and a mean follow-up of 45.7 months (range, 12-120 months). There were 317 one-part fractures, 165 two-part fractures, 137 three-part fractures, and 31 four-part fractures. The rate of radiographic union was 98% and the complication rate 13%. The average range of motion reported in five studies was 139° forward flexion, 48° external rotation, and 52° internal rotation. The average Constant score reported in six studies was 74 (range, 55-81). Varus malunion was the most common complication reported, whereas avascular necrosis was uncommon (13 cases). We conclude that our systematic review of the literature on the nonoperative treatment of proximal humerus fractures demonstrates high rates of radiographic healing, good functional outcomes, and a modest complication rate.

Medium-term results after total clavicle resection in cases of osteitis: a consecutive case series of five patients.

Claviculectomy is a rare and poorly described event in the surgical therapy of diseases of the clavicle. We present a case series and functional results of patients who underwent total claviculectomy. From 1995 to 2006 a total of 26 patients diagnosed with osteitis of the clavicle underwent surgery in our unit. Of these, five patients (all female) needed a total resection of the clavicle in order to ensure permanent healing from infection. The data collection was prospective. The data gathered preoperatively and at follow-up included clinical examinations, laboratory findings, radiographs and the Constant shoulder scores. The mean follow-up period was 7.5 months. The surgical concept described was able to eliminate infection in all cases studied within an average hospital stay of 13.4 days (8-18 days). Only one patient showed complications; suffering from chronic pain syndrome requiring surgical revision. After total resection of the clavicle four of five patients showed very good functional results. The average Constant score showed a significant increase from 82 before surgery to 95 at follow-up. The surgical technique described for total claviculectomy, along with the insertion of local antibiotic beads, was able to eliminate infection in every case. Good functional results and a low complication rates were observed. For good functional results and the permanent elimination of infection, adjacent joints have to be addressed, the periosteal tube should be preserved and early functional treatment is essential.

Arthroscopic treatment of calcifying tendinitis of the supraspinatus

Objective To investigate the pathological features and clinical outcomes of the arthroscopic treatment for calcifying tendinitis of the supraspinatus. Methods From March 2009 to October 2010,34 patients with calcifying tendinitis of the supraspinatus were treated with shoulder arthroscopy. Based on size of calcifying deposits, they were divided into three groups: small (＜10 mm), middle (≥ 10 mm, ≤20mm), and large (＞20 mm). All patients underwent arthroscopic calcium excision and subacromial decompression, and acromioplasty of shoulder was performed in 8 cases, rotator cuff neoplasty in 10. The preoperative and postoperative clinical data such as Constant's score, Visual Analog Scale (VAS) pain score and radiographs were adopted for evaluation. Besides, histological and scanning electronic microscopic examinations of calcium deposits were also carried out. Results All patients were follwed up for average 11.5 months.The patients were regularly examined at a time point of 1 month preoperatively, 2 days preoperatively and of the latest follow-up. The average Constant score was 36.1 ±6.9, 55.6±12.4 and 89.7±2.7 respectively; the average VAS pain score was 8.2±0.8,7.03±0.7,1.7±0.3 respectively. Both scoring systems revealed a significant difference before and after surgery. However, the clinical outcomes of the calcified deposit (small, middle, and large) showed on significant difference among the 3 groups. Collagen fibers were not degenerated around the calcified deposit, and no apoptotic or dead cells could be found, therefore, it is not a pathological calcification. Conclusion Recognition of calcifying tendinitis and good timing of surgery are keys to good clinical results. Shoulder arthroscopy is a safe, effective and minimally invasive method for the treatment of calcifying tendinitis of the supraspinatus. The patients with various size of the calcium deposit treated with shoulder arthroscopy can lead to an excellent clinical outcome postoperatively. Key words: Shoulder joint; Tendinopathy; Calcinosis; Arthroscopy