Axillary View Research Articles

Indication for Computed Tomography Scan in Shoulder Instability: Sensitivity and Specificity of Standard Radiographs to Predict Bone Defects After Traumatic Anterior Glenohumeral Instability.

Background:Quantifying glenohumeral bone loss is key in preoperative surgical planning for a successful Bankart repair.Hypothesis:Simple radiographs can accurately measure bone defects in cases of recurrent shoulder instability.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A true anteroposterior (AP) view, alone and in combination with an axillary view, was used to evaluate the diagnostic properties of radiographs compared with computed tomography (CT) scan, the current gold standard, to predict significant bone defects in 70 patients. Sensitivity, specificity, and positive and negative predictive values were evaluated and compared.Results:Detection of glenoid bone loss on plain film radiographs, with and without axillary view, had a sensitivity of 86% for both views and a specificity of 73% and 64% with and without the axillary view, respectively. For detection of humeral bone loss, the sensitivity was 8% and 17% and the specificity was 98% and 91% with and without the axillary view, respectively. Regular radiographs would have missed 1 instance of significant bone loss on the glenoid side and 20 on the humeral side. Interobserver reliabilities were moderate for glenoid detection (κ = 0.473-0.503) and poor for the humeral side (κ = 0.278-0.336).Conclusion:Regular radiographs showed suboptimal sensitivity, specificity, and reliability. Therefore, CT scan should be considered in the treatment algorithm for accurate quantification of bone loss to prevent high rates of recurrent instability.

Palmaris longus tendon graft versus modified Weaver-Dunn procedure via dynamic button system for acromioclavicular joint reconstruction in chronic cases

The hypothesis of this clinical study was that coracoclavicular (CC) reconstruction using autogenic palmaris longus graft through the GraftRope (PLG) system (Arthrex, Inc., Naples, FL, USA) would provide superior clinical and radiologic results compared with modified Weaver-Dunn procedure with the dynamic TightRope (Arthrex, Inc.) system (WDT). Between 2008 and 2013, 32 patients (average age, 39.7 years; range, 22-60 years) underwent surgical reconstruction of chronic acromioclavicular (AC) joint dislocation. A modified WDT procedure was performed in 16 patients and autogenous PLG was performed in the other 16 patients. Patient data were collected retrospectively, with a final follow-up of 44.9 months (range, 29-60 months). The degree of AC joint displacement was evaluated by measuring the CC distance on the anteroposterior and axillary view. Clinical and functional outcomes were compared by American Shoulder and Elbow Surgeons and the Constant scores at final follow-up. Comparison between the WDT and PLG groups showed a significantly better outcome in the American Shoulder and Elbow Surgeons and the Constant scores (P < .01), in favor of the PLG group. Both groups showed an increased CC distance compared with the uninjured side, with a mean difference of 1.1 mm for the PLG and 3.3 mm for the WDT groups. A tolerable loss of reduction within the follow-up time was observed. Reduction loss was higher with the WDT group (P < .05). CC palmaris longus tendon graft reconstruction with GraftRope system was associated with functional and radiologic benefits. The palmaris longus graft with GraftRope system could be used in chronic cases.

Prevalence of remaining horizontal instability in high-grade acromioclavicular joint injuries surgically managed.

To determine the prevalence of remaining horizontal instability in high-grade acromioclavicular joint (ACJ) injuries surgically managed by means of four different surgical strategies and to assess its relation to the clinical outcomes and the quality of life. In this multicentric non-randomized retrospective study, 53 patients with high-grade ACJ injuries surgically managed (by means of open or arthroscopic surgery) were clinically and radiographically assessed at 24months or more after shoulder surgery. The presence of post-surgical remaining horizontal instability was evaluated by means of Alexander or axillary X-ray views. The study population was divided into two groups: patients with evidence of post-surgical remaining horizontal instability and patients without evidence of post-surgical remaining horizontal instability at the last follow-up visit. The relationship between remaining horizontal instability and the quality-of-life questionnaires was analyzed. 18.87% (10/53) of the Alexander or axillary X-rays views showed post-surgical remaining horizontal instability at the last follow-up visit (INSTAB-group). Results of the questionnaires were: (1) physical SF36 score (INSTAB-group 57.02±3.17 and NO-INSTAB-group 57.66±3.30, p=0.583); (2) mental SF36 score (INSTAB-group 53.95±3.98 and NO-INSTAB-group 55.71±3.30, p=0.150); (3) NRS for pain (INSTAB-group 1.30±1.49 and NO-INSTAB-group 0.83 ±1.08, p=0.260); (4) DASH questionnaire (INSTAB-group 5.27±5.42 and NO-INSTAB-group 3.06±2.30, p=0.049); (5) Constant score (INSTAB-group 93.4±3.5 and NO-INSTAB-group 94.83 ±4.3, p=0.333); and Global satisfaction (INSTAB-group 8.7 ±0.95 and NO-INSTAB-group 8.64±1.03, p=0.874). Independently of the type of procedure, post-surgical remaining horizontal instability was present in almost one-fifth of the patients, and this group of patients showed a significantly worse DASH score. The addition of an acromioclavicular augmentation might have to be considered, taking into account that its absence may have a negative impact in terms of shoulder disabilities. Level IV, prognostic case series.

Reverse Total Shoulder Arthroplasty: Salvage Procedure for Failed Prior Arthroplasty.

BackgroundTo evaluate the clinical outcome of revision of primary shoulder replacement by using reverse total shoulder arthroplasty (RTSA).MethodsSeven patients underwent revision RTSA with a mean follow-up of 22.1 months (range, 12 to 54 months). Their mean age at the time of operation was 75.5 years (range, 70 to 80 years). Assessments were performed on the preoperative and postoperative visual analogue scale (VAS) score, muscle strength, range of motion, University of California at Los Angeles (UCLA) score, Constant score, subjective satisfaction and the anteroposterior and axillary views of the glenohumeral joint. The primary operation was hemiarthroplasty in 5 patients, total shoulder replacement in 1 patient, and reverse shoulder arthroplasty in 1 patient. The cause of revision surgery was infection in 2 patients, humeral stem loosening in 2 patients, glenoid arthropathy in 2 patients, and glenoid loosening in 1 patient. The mean duration from primary operation to revision surgery was 52 months (range, 27 to 120 months).ResultsThe VAS score for pain during motion was improved from 7.3 preoperatively to 2.1 postoperatively (p = 0.03). There were increases in the mean active forward flexion (from 62.1° to 92.8°), abduction (from 70° to 87.1°), external rotation (from 44.2° to 47.4°), and internal rotation (from L5 to L4; p > 0.05) postoperatively. Performance in activities of daily living improved (p > 0.05), except for lifting 10 lb above the shoulder (from 1.2 to 1.1; p = 0.434). Overall, 5 of 7 patients were satisfied with the results of revision surgery. The mean Constant score improved from 44.8 preoperatively to 57.1 postoperatively (p = 0.018). The mean UCLA score improved from 12.8 preoperatively to 22.8 postoperatively (p = 0.027). In the postoperative radiological evaluation, no radiolucency was observed around the base plate or humeral stem.ConclusionsPain could be reduced after revision RTSA, but improvements in range of motion and function were difficult to achieve. We think that the patients' satisfaction was relatively high despite the low function score due to the preoperative severe pain and marked limitation of range of motion.

BiPOD Arthroscopic Acromioclavicular Repair Restores Bidirectional Stability.

Stabilizing the acromioclavicular joint in the vertical and horizontal planes is challenging, and most current techniques do not reliably achieve this goal. The BiPOD repair is an arthroscopically assisted procedure performed with image intensifier guidance that reconstructs the coracoclavicular ligaments as well as the acromioclavicular ligaments to achieve bidirectional stability. Repair is achieved with a combination of 2-mm FiberTape (Arthrex, Naples, Florida) and 20-mm Poly-Tape (Neoligaments, Leeds, England) to achieve rigid repair, prevent bone abrasion, and promote tissue ingrowth. This study is a prospective review of the first 6 patients treated for high-grade acute acromioclavicular injury with the BiPOD technique. The study included 6 men who were 21 to 36 years old (mean, 27 years). At 6-month follow-up, complications were recorded and radiographic analysis was used to determine the coracoclavicular distance for vertical reduction and the amount of acromioclavicular translation on the Alexander axillary view was used to determine horizontal reduction. One patient had a superficial infection over the tape knot. The difference in coracoclavicular distance between the operated side and the uninvolved side was 9±2 mm preoperatively and 0.3±2 mm at 6-month follow-up. On Alexander axillary view, all 6 patients showed stable reduction, which is defined as a clavicle that is in line with the acromion. The findings show that BiPOD acromioclavicular reconstruction restores bidirectional stability of the acromioclavicular joint at 6 months. [Orthopedics. 2017; 40(1):e35-e43.].

Anatomical principles for minimally invasive reconstruction of the acromioclavicular joint with anchors.

The aim of this study was to evaluate the outcome of a minimally invasive surgical technique for the treatment of patients with acromioclavicular joint dislocation. Sixteen patients with complete acromioclavicular joint dislocation were enrolled in this study. All patients were asked to follow the less active rehabilitation protocol post-operatively. Computed tomography with 3-D reconstruction of the injured shoulder was performed on each patient post operatively for the assessment of the accuracy of the suture anchor placement in the coracoid process and the reduction of the acromioclavicular joint. Radiographs of Zanca view and axillary view of both shoulders were taken for evaluating the maintenance of the acromioclavicular joint reduction at each follow-up visit. The Constant shoulder score was used for function assessment at the final follow-up. Twenty seven of the 32 anchors implanted in the coracoid process met the criteria of good position. One patient developed complete loss of reduction and another had partial loss of reduction in the anteroposterior plane. For the other 14 patients, the mean Constant score was 90 (range, 82-95). For the patients with partial and complete loss of reduction, the Constant score were 92 and 76 respectively. All of them got nearly normal range of motion of the shoulders and restored to pre-operative life and works. With this minimally invasive approach and limited exposure of the coracoid, a surgeon can place the suture anchors at the anatomical insertions of the coracoclavicular ligament and allow the dislocated joint reduced and maintained well. Level IV, Case series; therapeutic study.

Improving the diagnostic quality and adequacy of shoulder radiographs in a District General Hospital

A high rate of suboptimal shoulder radiographs was identified during a service evaluation exercise in our orthopaedic outpatient clinics. Inadequate radiographs require a return to the radiology department for further...

Clinical and Radiographic Mid-Term Outcomes After Total Shoulder Replacement: A Retrospective Study Protocol Including 400 Anatomical and Reverse Prosthetic Implants.

To obtain outcomes data on anatomical and reverse total shoulder arthroplasty by analysis of clinical scores and standard radiographs. 400 consecutive series of patients replaced with anatomical and reverse total shoulder arthroplasty (minimum 3 years follow-up). retrospective monocenter. Demographics, clinical scores (Constant-Murley) as available, shoulder X-ray (AP, outlet and axillary views) . Postoperative radiographhs and clinical scores. Adverse events and complications to be reported as occurred since implantation. Data collected will be summarized and analyzed for statistical significance.

Arthroscopic reduction and fixation of large solitary and multifragmented anterior glenoid rim fractures

The optimal treatment of large anterior glenoid rim fractures is still a matter of debate. The purpose of this study was to evaluate the clinical and radiologic results of an arthroscopic reduction and fixation of acute displaced large solitary or multifragmented anterior glenoid rim fractures using anchors or bioabsorbable compression screws. Twenty-three consecutive patients (7 women, 16 men; mean age, 47.9 [15-74] years) were treated. The patients were followed up clinically (range of motion, instability testing, and shoulder outcome scores) and with conventional radiographs (true anterior-posterior, axillary, and Bernageau views). With a minimum follow-up of 24months, 21 patients could be evaluated. The average Constant score was 84.5 points, the Rowe score was 90.8 points, the Melbourne Instability Shoulder Score was 96.2 points, the Western Ontario Shoulder Instability Index was 89.2%, and the subjective shoulder value averaged 92.1%. No patient had suffered recurrent instability. The radiologic evaluation revealed signs of osteoarthritis in 7 cases, which was pre-existing in 1 patient. Patients with osteoarthritis were on average 10years older at the time of surgery compared with patients without osteoarthritis. A postoperative step-off of the glenoid was detected in 7 cases and averaged 2 (1-3) mm. We could not find a correlation between the step-off and the presence of osteoarthritis. Arthroscopic reconstruction of acute large solitary and multifragmented fractures of the glenoid rim shows good and excellent clinical results. In the majority of cases, an anatomic reduction and healing of the glenoid fracture can be achieved. The rate of osteoarthritis needs further investigation.

Reliability of radiographic measurements for acromioclavicular joint separations

IntroductionThe treatment of acromioclavicular (AC) joint separations is controversial, particularly for Rockwood type III injuries. Rockwood type IV injuries, which correspond to horizontal instability, are very likely under-diagnosed. The objective of this study was to evaluate the inter- and intra-observer reproducibility of the Rockwood classification through an evaluation of standard radiographs, as described in the original article. Material and methodsThis was a prospective radiographic study using protocol-based data from the 2014 symposium of the French Society of Arthroscopy (SFA). Fifteen anonymized radiological records were analysed by six independent examiners on two occasions, 1 week apart. The records consisted of a comparative A/P view of the two acromioclavicular joints (Zanca view), an axillary lateral view and dynamic lateral views (Tauber protocol) to uncover dynamic horizontal instability. A detailed analysis protocol was implemented that included absolute and relative measurements on each view; the relative measurements were used to account for radiographic magnification. ResultsThe inter- and intra-observer reproducibility on the A/P radiographs was good to excellent. The reproducibility was fair to good on the lateral views, but the measurements varied greatly from one subject to another, and significant errors were found with certain records. The reproducibility of the dynamic views proposed by Tauber was poor to fair. DiscussionRadiographic analysis of AC joint separations is reproducible in the vertical plane, which makes it possible to diagnose Rockwood type II, III and V injuries. On the other hand, static and dynamic analyses in the horizontal plane do not have good reproducibility and do not contribute to make an accurate diagnosis of Rockwood type IV injuries. Level of evidenceLevel I, Diagnostic study.

Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?

BackgroundThe primary objective was to evaluate correlations linking anatomical to functional outcomes after endoscopically assisted repair of acute acromioclavicular joint dislocation (ACJD). HypothesisCombined acromioclavicular and coracoclavicular stabilisation improves radiological outcomes compared to coracoclavicular stabilisation alone. Material and methodsA prospective multicentre study was performed. Clinical outcome measures were pain intensity on a visual analogue scale (VAS), subjective functional impairment (QuickDASH score), and Constant's score. Anatomical outcomes were assessed on standard radiographs (anteroposterior view of the acromioclavicular girdle and bilateral axillary views) obtained preoperatively and postoperatively and on postoperative dynamic radiographs taken as described by Tauber et al. ResultsOf 116 patients with acute ACJD included in the study, 48% had type III, 30% type IV, and 22% type V ACJD according to the Rockwood classification. Coracoclavicular stabilisation was achieved using a double endobutton in 93% of patients, and concomitant acromioclavicular stabilisation was performed in 50% of patients. The objective functional outcome was good, with an unweighted Constant's score≥85/100 and a subjective QuickDASH functional disability score≤10 in 75% of patients. The radiographic analysis showed significant improvements from the preoperative to the 1-year postoperative values in the vertical plane (decrease in the coracoclavicular ratio from 214 to 128%, p=10−6) and in the horizontal plane (decrease in posterior displacement from 4 to 0mm, p=5×10−5). The anatomical outcome correlated significantly with the functional outcome (absolute R value=0.19 and p=0.045). We found no statistically significant differences across the various types of constructs used. Intra-operative control of the acromioclavicular joint did not improve the result. Implantation of a biological graft significantly improved both the anatomical outcome in the vertical plane (p=0.04) and acromioclavicular stabilisation in the horizontal plane (p=0.02). The coracoclavicular ratio on the anteroposterior radiograph was adversely affected by a longer time from injury to surgery (p=0.02) and by a higher body mass index (BMI) (p=0.006). High BMI also had a negative effect on the difference in the distance separating the anterior edge of the acromion from the anterior edge of the clavicle between the injured and uninjured sides, as assessed on the axillary views (p=0.009). ConclusionThis study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint. Coracoclavicular stabilisation alone is not sufficient, regardless of the type of implant used. Implantation of a biological graft should be considered when the time from injury to surgery is longer than 10days. The weight of the upper limb should be taken into account, with 6weeks of immobilisation to unload the construct in patients who have high BMI values. Level of evidenceII, prospective non-randomised comparative study.

Does lateralisation of the centre of rotation in reverse shoulder arthroplasty avoid scapular notching? Clinical and radiological review of one hundred and forty cases with forty five months of follow-up

Our purpose was to evaluate the influence of metallic lateralisation of the centre of rotation (COR) in reverse shoulder arthroplasty (RSA) on the incidence of scapular notching and its eventual clinical and radiological consequences. We analysed 140 RSAs with a lateralised design (Arrow, FH Orthopedics, Mulhouse, France) implanted for massive rotator cuff tear with/without arthritis. Mean follow-up was 45 months (range 24-120, standard deviation 20). Patients were evaluated clinically using the Constant and Murley (Clin Orthop Relat Res 214:160-164, 1987) score and active range of motion (ROM) and radiologically using standard anteroposterior and axillary view. Scapular notching was assessed according to Sirveaux classification Simovitch et al. (J Bone Joint Surg Am, 89:588-600, 2007), and patients were separated into two groups (scapular notch/no scapular notch) and compared. Forty-one notches (29 %) were found: 20 grade 1, 18 grade 2, and three grade 3. The latter three patients had a follow-up of 44, 70 and 84 months, respectively, and the scapular notch did not evolve in the final two years. Better pre-operative function was significantly associated with scapular notching (p < 0,05 for flexion and abduction), but no final clinical differences in ROM and Constant score were found between groups. A body mass index (BMI) <30 increased the risk of scapular notching, which was observed in 43 % of patients with a BMI < 30 and 30 % of patients with a BMI > 30 p = 0,048). Pre-operative narrowing of the subacromial space increased the risk of scapular notching, but age or gender showed no influence. However, there was a significantly greater number of scapular notches in patients operated on the dominant side (p = 0,04). No significant difference in lateral offset was found between groups (p = 0,99). Glenoid implantation in an excessively high position (p = 0,033) and absence of inferior tilt (p = 0,0029) were significantly associated with scapular notching. In this series, metallic lateralisation of the COR in RSA did not impair clinical results, with patients achieving good flexion recovery ROM increase in rotations. Metallic lateralisation of the COR in RSA leads to a lower incidence of scapular notching (29 %) compared with previously reported results using other arthroplastic systems with a more medialised COR. However, although scapular notching was not totally eliminated, those that were found did not evolve over time. Several factors increased the incidence of scapular notching: BMI <30, better preoperative ROM, an excessively high glenoid implant and absence of inferior tilt.

Arthroscopically assisted stabilization of displaced lateral clavicle fractures with coracoclavicular instability.

Lateral clavicle fractures associated with partial or complete injury of the coracoclavicular ligaments have traditionally been treated using a variety of open surgical techniques. The aim of this prospective study was the evaluation of the clinical and radiologic outcome of displaced lateral clavicular fractures with coracoclavicular instability treated in an arthroscopic single TightRope technique including an interfragmentary cerclage. From 2008 to 2010, 23 patients [8 women and 15 men; mean age 38 (24-63) years] who sustained a displaced lateral clavicular fracture type II according to Neer were included in this study. The follow-up consisted of a complete physical examination of the shoulder including range of motion, the constant score (CS), and the subjective shoulder value (SSV). The radiological follow-up included an anteroposterior stress view with 10 kg of axial load and bilateral axillary views to evaluate the coracoclavicular distance, the clavicular implant position, and healing of the fracture. After a mean follow-up of 23.0 (13-38) months, 20 patients (7 women and 13 men; mean age 38.3 (24-53) years) were available for follow-up. On average, patients achieved 95.1 (60-100) % in the SSV, 88.7 (64-99; contralateral side 91.8 points; p > 0.05) points in the CS. Radiologically, 18 of 20 patients (90 %) displayed a bony healing of the fracture. The average coracoclavicular distance of 11.2 (6-14) mm did not differ significantly from the healthy side [9.9 (8-14) mm]. In six cases (30 %), coracoclavicular ossifications appeared. Two of 20 patients had concomitant glenohumeral lesions (10 %). Two patients had secondary surgery [implant removal (N = 1 local implant irritation); plate osteosynthesis (N = 1 early loss of reduction)]. The arthroscopic-assisted and image intensifier-controlled closed reduction and single TightRope fixation with interfragmentary cerclage of displaced lateral clavicular fractures with coracoclavicular instability yields excellent clinical results and is able to recreate stability of the clavicle.

Reducción de dosis en mamografías de seguimiento tras cirugía conservadora de mama

Mammographic follow-up after surgery involves a larger number of views than that usually required for a screening mammogram. Some authors suggest the use of additional views in mammography after breast conserving therapy (BCT). However women treated with BCT had often already received a considerably high glandular dose due to additional views, short term follow-ups, or radiotherapy.An exaggerated medio-lateral oblique (XMLO) view is proposed as a dose-saving alternative to standard «medio-lateral oblique (MLO)+ axillary view (AX)».

The Axillary View Typically Does Not Contribute to Decision Making in Care for Proximal Humeral Fractures.

Convention dictates that an axillary view be obtained when evaluating proximal humerus fractures (PHF). However, the axillary view is frequently omitted because of pain and technical considerations. Furthermore, its diagnostic utility is unclear in this setting. The purpose of this study was to (1) determine the rate of obtaining an adequate axillary X-ray and complete shoulder series at a level I trauma center, (2) understand the cost of ordering and attempting an axillary radiograph, and (3) determine if axillary radiographs influence the management of PHF. PHF treated between 2009 and 2011 that were ordered for an AP, scapular Y, and axillary view was identified. The types of radiographs actually obtained were recorded. The cost of obtaining three views and a single view of the shoulder with X-ray was determined. Lastly, three surgeons reviewed 42 PHF, both with and without an axillary view (AV), and treatment recommendations were compared. 30% of PHF in this series had an adequate axillary view, and 14% received a complete trauma series. No factors could be identified that were associated with successfully obtaining an axillary view. Reviewers demonstrated substantial intraobserver reliability (κ = 0.759-0.808) regarding treatment recommendations for PHF with and without the axillary view. The addition of the AV had minimal influence on treatment recommendations. Considering that the axillary view for PHF is painful, labor-intensive, costly, and does not appear to provide additional diagnostic value, orthopedic surgeons can consider foregoing the use of the axillary view when evaluating and treating PHF, particularly if other advanced imaging is utilized.

Factors that Influence Reduction Loss in Proximal Humerus Fracture Surgery.

This study was performed to identify the risk factors for reduction loss after locking plate fixation of proximal humerus fractures. Retrospective study. University trauma center. We retrospectively evaluated 252 patients who had been surgically treated for proximal humeral fractures with locking plates between January 2004 and December 2011. Charts and standardized x-rays (true anteroposterior and axillary lateral views) were used to evaluate the Neer and AO OTA fracture types, initial neck-shaft angle (NSA, varus displacement), medial comminution, postoperative NSA (reduction adequacy), medial support restoration, healing progress, reduction loss, and implant-related problems immediately after surgery and at 2 weeks, 1 month, 3 months, 6 months, 9 months, and at least 1 year after surgery. Reduction loss was defined as (1) ≥10 of angulation in any direction, (2) ≥5 mm of height loss of the humeral head from the plate, and (3) fixation failure. Reduction loss occurred in 6.7% (17 of 252) of cases; revision surgeries were performed in all cases. Univariable logistic regression analysis revealed that older age (P = 0.023), osteoporosis (P = 0.001), varus displacement (P = 0.001), medial comminution (P = 0.001), reduction adequacy (P = 0.036), and insufficient medial support (P = 0.001) had significant correlations with reduction loss. Multivariable regression analysis revealed that osteoporosis (less than -2.5 bone mineral density, P = 0.015), displaced varus fracture (less than 110° of NSA, P = 0.025), medial comminution (more than 1 fragment, P = 0.018), and insufficient medial support (no cortical or screw support, P = 0.001) were independent risk factors for reduction loss in the proximal humerus fractures surgery. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Employment of synthetic patch with augmentation of the long head of the biceps tendon in irreparable lesions of the rotator cuff: our technique applied to 60 patients.

The aim of our study was to evaluate the effectiveness of both clinical and functional benefits after the surgical repair of the rotator cuff in irreparable lesions using a synthetic patch with augmentation of the long head of the biceps (LHB) tendon. This is a retrospective study analysis of a randomized series of 60 patients (45 women and 15 men; average age 66 y) who underwent open repair of irreparable rotator cuff tear with synthetic patch using LHB tendon augmentation between 1999 and 2008.The inclusion criteria were: patients painful symptomatology, presenting a deficit in elevation, who are not responsive to physiotherapy, irreparable tear size, minimum follow-up of 36 months after surgery, and active and motivated patients. We used a control group of 60 patients treated without employment of the synthetic patch and LHB tendon augmentation.Patients were evaluated preoperatively and after 36 months with a Visual Analog Scale (VAS) and the University of California, Los Angeles (UCLA) shoulder rating scale and by measuring elevation of the scapular plane and strength with a dynamometer. All the patients were assessed preoperatively also with plain radiographs (anteroposterior and axillary views), ultrasound, and NMRI of the shoulder. The VAS and UCLA scores were also obtained 3 months postoperatively. Tendon integrity was assessed after 1 year by NMRI. Statistical analysis was conducted by 1-way analysis of variance between groups of treatment, with Dunnett post hoc correction for multiple comparisons. P-values ≤ 0.05 were considered as statistically significant. This surgical technique consisted in a short deltoid splitting, irreparable lesion evaluation, and, after tenodesis, the proximal segment of the LHB tendon was sutured to the remaining cuff tendons to fill the gap of the corresponding lesion. To shield the repaired rotator cuff we inserted a synthetic patch. Satisfactory results were achieved in 52 of the patients treated with this procedure; after 3 months the mean VAS was 6.85 ± 1.11 versus 4.9 ± 0.9, whereas the mean UCLA was 11.28 ± 1.43 versus 20.85 ± 1.27, respectively, for control and prolene group. After 36 months the mean VAS was 3.7 ± 1.01 versus 3.23 ± 1.07, whereas the mean UCLA was 14.73 ± 1.96 versus 24.6 ± 3.3, respectively, for control and prolene group. In addition, after 36 months elevation on the scapular plane was 140.75 ± 10.48 degrees versus 174.75 ± 8.1 degrees and abduction strength was 8.57 kg ± 0.63 versus 13.61 kg ± 0.84, respectively, for control and prolene group (P-value = 0.005). Re-tear rate after 12 months was 40% (24/60) in the control group and 15% (9/60) in the prolene group. No adverse side effects (infection, rejection, allergy) were reported during the study period. The results of our study suggest that employing this surgical technique in patients (appropriately selected) with an irreparable rotator cuff tear can lead to pain relief and improved clinical outcome.

Can the ream and run procedure improve glenohumeral relationships and function for shoulders with the arthritic triad?

The arthritic triad of glenoid biconcavity, glenoid retroversion, and posterior displacement of the humeral head on the glenoid is associated with an increased risk of failure of total shoulder joint replacement. Although a number of glenohumeral arthroplasty techniques are being used to manage this complex pathology, problems with glenoid component failure remain. In that the ream and run procedure manages arthritic pathoanatomy without a glenoid component, we sought evidence that this procedure can be effective in improving the centering of the humeral head contact on the glenoid and in improving the comfort and function of shoulders with the arthritic triad without the risk of glenoid component failure. We asked, for shoulders with the arthritic triad, whether the ream and run procedure could improve glenohumeral relationships as measured on standardized axillary radiographs and patient-reported shoulder comfort and function as recorded by the Simple Shoulder Test. Between January 1, 2006 and December 14, 2011, we performed 531 primary anatomic glenohumeral arthroplasties for arthritis, of which 221 (42%) were ream and run procedures. Of these, 30 shoulders in 30 patients had the ream and run procedure for the arthritic triad and had two years of clinical and radiographic follow-up. These 30 shoulders formed the basis for this case series. The average age of the patients was 56±8years; all but one were male. Two of the 30 patients requested revision to total shoulder arthroplasty within the first year after their ream and run procedure because of their dissatisfaction with their rehabilitation progress. For the 28 shoulders not having had a revision, we determined on the standardized axillary views before and after surgery the glenoid type, glenoid version (90° minus the angle between the plane of the glenoid face and the plane of the body of the scapula), and location of the humeral contact point with respect to the anteroposterio dimension of the glenoid (the ratio of the distance from the anterior glenoid lip to the contact point divided by the distance between the anterior and posterior glenoid lips). We also recorded the patient's self-assessed shoulder comfort and function before and after surgery using the 12 questions of the Simple Shoulder Test. For the 28 unrevised shoulders the mean followup was 3.0years (range, 2-9.2years). In these patients, the ream and run procedure resulted in improved centering of the humeral head on the face of the glenoid (preoperative: 75%±7% posterior; postoperative: 59%±10% posterior; mean difference 16% [95% CI, 13%-19%]; p<0.001), notably this improved centering was achieved without a significant change in the glenoid version. Patient-reported function was improved (preoperative Simple Shoulder Test: 5±3, postoperative Simple Shoulder Test: 10±4, mean difference 5 [95% CI, 4-6], p<0.001). For shoulders with the arthritic triad, the ream and run procedure can provide improvement in humeral centering on the glenoid and in patient-reported shoulder comfort and function without the risk of glenoid component failure. In that ream and run is a new procedure, substantial additional clinical research with long-term follow-up is needed to define specifically the shoulder characteristics, the patient characteristics and the technical details that are most likely to lead to durable improvements in the comfort and function of shoulders with the challenging pathology known as the arthritic triad. Level IV, therapeutic study.

Which parameters affect medium- to long-term results after angular stable plate fixation for proximal humeral fractures?

Very little information on medium- to long-term results is available for surgically treated proximal humeral fractures. The aim of this prospective treatment study was to present long-term results after angular stable plate fixation of displaced proximal humeral fractures and to detect which specific patient- and fracture-related parameters affect the clinical outcome. We performed a prospective clinical and radiologic evaluation of 77 patients with a displaced proximal humeral fracture (28 Neer 2-part, 38 3-part, and 11 4-part fractures; 28 AO A fractures, 30 AO B fractures, and 19 AO C fractures) treated with angular stable plate fixation after a mean follow-up period of 96 months (range, 74-133 months). We assessed outcomes with the Constant, University of California-Los Angeles (UCLA), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores and evaluated specific patient- and fracture-related parameters including complications. The mean Constant, University of California-Los Angeles (UCLA), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were 79, 31, and 12 points. Reasons for revisions were implant-related impingement (n = 13), screw perforation (n = 10), infection (n = 4), and secondary fracture displacement (n = 1). There was a significant association between worse score results and occurrence of secondary fracture displacement, screw perforation, residual bone deformities, and a rotator cuff defect at follow-up. Good medium- to long-term results after angular stable plate fixation of displaced proximal humeral fracture can be expected. A reconstruction within a range of 15° in both anteroposterior and axillary views and <5-mm tuberosity displacement should be the aim of head-preserving surgery to prevent complications, such as secondary fracture displacement and screw perforation, and a less favorable long-term result.

Cirugía de Latarjet abierta con técnica mini-open: revisión de conceptos actuales

The incidence of traumatic shoulder instability is 1.7% in the general population. The shoulder bone structure provides inherent instability to the joint. The surgeon must study the patient age, dominance and activity, as well as the number and direction of the dislocations, and finally the general conditions of the soft tissues. Initial radiographs include anteroposterior and axillary or Velpeau view, in case of bone injury an AP internal rotation and Stryker view or axillary view should be taken. Magnetic Resonance Imaging allows the study of associated soft tissue injuries. It has been described a number of surgical treatments for recurrent shoulder instability, nevertheless, arthroscopic Bankart repair is the most used. An anterior glenoid defect has been reported in 90% of cases with recurrent anterior shoulder instability. This kind of injuries might require other treatment methods such as transferring the coracoid process, which works by the so called triple lock concept. This surgery is also indicated in cases of glenoid bone defect and subscapularis rupture. The surgical technique has proved to be reproducible through the years and the rehabilitation process is rapid allowing an early return to sports. Complications are mostly secondary to technical mistakes. Recent studies report 96% of satisfaction with only 1% of patients requiring revision surgery. However, it is considered that there is insufficient evidence to consider Latarjet's technique a better technique, despite of better results reported when comparing subjective assessment of mobility, stability and so far by subjective functional tests. Evidence levelIV