External Rotation In Patients Research Articles

Outcomes After Double-Layer Repair Versus En Masse Repair for Delaminated Rotator Cuff Injury: A Systematic Review and Meta-analysis.

Delamination of rotator cuff tears during arthroscopic shoulder surgery has an incidence of 38% to 92%. Double-layer (DL) repair and en masse (EM) repair are most commonly used in this situation. To compare the clinical results of the DL versus EM repair techniques for delaminated rotator cuff tears using a meta-analysis. Systematic review; level of evidence, 3. We identified relevant studies comparing the clinical results of DL and EM repair for delaminated rotator cuff injuries in the PubMed, Embase, and Cochrane databases after the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The primary outcomes were the Constant score and retear rate. Additionally, we compared other postoperative shoulder functional scores, shoulder range of motion, and visual analog scale (VAS) pain scores between the 2 suture methods using a meta-analysis. The mean difference (MD) was compared for continuous outcomes, and the odds ratios (ORs) were compared for categorical outcomes. Of the 197 studies initially identified, 6 studies were included in this analysis. There were significant differences in the Constant score (MD, 8.64 [95% CI, 4.47 to 12.8]; P < .05) and external rotation (MD, 5.10 [95% CI, 2.63 to 7.56]; P < .05) between the 2 techniques, with DL repair having superior outcomes. No significant differences were observed between the 2 techniques in forward flexion (MD, 0.62 [95% CI, -1.18 to 2.43]; P = .50), VAS pain (MD, -0.03 [95% CI, -0.34 to 0.27]; P = .84), or retear rate (OR, 0.73 [95% CI, 0.37 to 1.41]; P = .35). Results of this review and meta-analysis suggest that DL repair was more beneficial than EM repair in terms of the Constant score and shoulder external rotation in patients with delaminated rotator cuff injuries.

Can Lateralization of Reverse Shoulder Arthroplasty Improve Active External Rotation in Patients with Preoperative Fatty Infiltration of the Infraspinatus and Teres Minor?

(1) Background: Postoperative recovery of external rotation after reverse shoulder arthroplasty (RSA) has been reported despite nonfunctional external rotator muscles. Thus, this study aimed to clinically determine the ideal prosthetic design allowing external rotation recovery in such a cohort. (2) Methods: A monocentric comparative study was retrospectively performed on patients who had primary RSA between June 2013 and February 2018 with a significant preoperative fatty infiltration of the infraspinatus and teres minor. Two groups were formed with patients with a lateral humerus/lateral glenoid 145° onlay RSA—the onlay group (OG), and a medial humerus/lateral glenoid 155° inlay RSA—the inlay group (IG). Patients were matched 1:1 by age, gender, indication, preoperative range of motion (ROM), and Constant score. The ROM and Constant scores were assessed preoperatively and at a minimum follow-up of two years. (3) Results: Forty-seven patients have been included (23 in OG and 24 in IG). Postoperative external rotation increased significantly in the OG only (p = 0.049), and its postoperative value was significantly greater than that of the IG by 11.1° (p = 0.028). (4) Conclusion: The use of a lateralized humeral stem with a low neck-shaft angle resulted in significantly improved external rotation compared to a medialized humeral 155° stem, even in cases of severe fatty infiltration of the infraspinatus and teres minor. Humeral lateralization and a low neck-shaft angle should be favored when planning an RSA in a patient without a functional posterior rotator cuff.

Improved long-term functional outcome after a latissimus dorsi transfer with or without subscapularis muscle lengthening or release

A brachial plexus birth injury (BPBI) can lead to a limited shoulder function, especially abduction and external rotation. One of the treatment options to restore those shoulder functions is a latissimus dorsi transfer (LDT). The aim of this study is to analyze long-term functional outcome after a single LDT and compare these results with LDT combined with subscapularis muscle lengthening (SSL) or subscapularis muscle release (SSR). This cohort study included 39 patients (≤12 years old) with one-sided BPBI. All patients had an inter- nal rotation- and adduction contracture without glenohumeral joint deformity. A LDT was performed with or without SSL or SSR, resulting in 3 patient study groups. Demographic data and pre- and post- operative Mallet scores were collected and analysed for each group. The median age was 4.0 years (IQR 3.1) and there were no differences in patient demographics. In all patients surgery improved external rotation and overall shoulder function, at 9.8 years follow-up. Also, the total Mallet score increased significantly with 1.7 (p=0.001) in our (entire) study cohort. A LDT, with a SSL or SSR in case of an intra-operative internal contracture, improves shoulder function and preserves external rotation in patients (≤12 years old) with BPBI, at a follow up of 9.8 years.

Effectiveness of Kaltenborn Posterior Glide and Coracohumeral Ligament Positional Stretching on External Rotation Range of Motion in Patients with Adhesive Capsulitis

Background:Adhesive capsulitis is a common and debilitating medical condition which is treated by varioussurgical and non-surgical treatments but there is no significant method universally. Physical therapists usevarious shoulder mobilization techniques to improve the ROM. Radiographic and surgical evidence presentstightened CHL to be a prime contributor to inadequate shoulder external rotation in individuals diagnosedwith adhesive capsulitis.Objective: To determine the combined effectiveness of Kaltenborn posterior glide and coracohumeralligament (CHL) positional stretching on external rotation in patients with adhesive capsulitis.Methods and Measures:A number of 30 subjects, both Male and Female with a primary diagnosis ofshoulder adhesive capsulitis by the physician were recruited. 15 subjects each were randomly assignedto Group-A(Experimental) and Group-B(control). All subjects received 6 therapy sessions consisting ofmoist heat, shoulder pendular and ROM exercises, Kaltenborn posterior glide and Coracohumeral ligamentpositional stretching in Group-A. Moist heat, shoulder pendular and ROM exercises in Group-B. Pre-testand post-test were carried out for both the groups and analysed using paired and independent t tests in anSPSS software.Results: The experimental group(Group-A) mean VAS score had decreased from 6.27 to 3.73, SPADI meanscore decreased from 0.534 to 0.380 and also Goniometer (Shoulder external ROM) showed an improvementfrom 29.2 to 35.33 but when intergroup analysis was done, it resulted in significance only for SPADI wherep &lt; 0.05. Through this measure, we can state that the treatment protocol for group A had a significantimprovement in disability but not much on pain and ROM in patients with adhesive capsulitis.Conclusion: All the interventions has brought about some improvement in each group post-treatment basedon the mean score but its significance vary. So, this study can be concluded that, the treatment protocol,Kaltenborn posterior glide and CHL positional stretching could bring a significant difference with regard todisabilty but not much of difference in pain and ROM in patients with adhesive capsulitis.

Étude 3D des mouvements après transfert de tendon du grand dorsal pour rupture massive postéro-supérieure de la coiffe des rotateurs: analyse de la proprioception et des capacités à effectuer les gestes de la vie courante

BackgroundMassive irreparable posterosuperior rotator cuff tears may result in a loss of external rotation. Most of these patients lose their ability to perform activities of daily living (ADLs), especially where external rotation and abduction are needed. Latissimus dorsi tendon transfer (LDTT) is a method to restore abduction and external rotation in patients with posterosuperior rotator cuff tears. There are no objective data concerning whether LDTT can restore range of motion (ROM), especially in performing ADLs and if proprioception changes after LDTT. MethodsWe examined 12 patients 4.2 years (1–9 years) after LDTT with simultaneous 3D motion analysis; the opposite, nonaffected side was assessed as control. The measurement protocol included maximum values in flexion/extension, abduction/adduction, internal/external rotation in 0° and in 90° flexion and in 90° abduction. To evaluate competences, we measured seven activities of daily life and examined the proprioceptive ability using an active angle reproduction test. Results4.2 years (1–9 years) after LDTT there was no significant difference in flexion/extension and abduction/adduction compared to the healthy side. Maximum external rotation was significantly reduced compared to the opposite side. Eleven patients (85 %) were able to perform all ADL. Proprioceptive ability did not differ from the healthy side. ConclusionLDTT cannot fully restore a patient's ability for external rotation after a posterosuperior rotator cuff tear. However, 4.2 years after surgery, 85 % of the patients are able to perform all ADLs. Proprioceptive ability is not affected by the transfer.

3D motion analysis of latissimus dorsi tendon transfer in patients with posterosuperior rotator cuff tears: Analysis of proprioception and the ability to perform ADLS

BackgroundMassive irreparable posterosuperior rotator cuff tears may result in a loss of external rotation. Most of these patients lose their ability to perform activities of daily living (ADLs), especially where external rotation and abduction are needed. Latissimus dorsi tendon transfer (LDTT) is a method to restore abduction and external rotation in patients with posterosuperior rotator cuff tears. There are no objective data concerning whether LDTT can restore range of motion (ROM), especially in performing ADLs and if proprioception changes after LDTT. MethodsWe examined 12 patients 4.2 years (1–9 years) after LDTT with simultaneous 3D motion analysis; the opposite, nonaffected side was assessed as control. The measurement protocol included maximum values in flexion/extension, abduction/adduction, internal/external rotation in 0° and in 90° flexion and in 90° abduction. To evaluate competences, we measured seven activities of daily life and examined the proprioceptive ability using an active angle reproduction test. ResultsIn total, 4.2 years (1–9 years) after LDTT there was no significant difference in flexion/extension and abduction/adduction compared to the healthy side. Maximum external rotation was significantly reduced compared to the opposite side. Eleven patients (85%) were able to perform all ADL. Proprioceptive ability did not differ from the healthy side. ConclusionLDTT cannot fully restore a patient's ability for external rotation after a posterosuperior rotator cuff tear. However, 4.2 years after surgery, 85% of the patients are able to perform all ADLs. Proprioceptive ability is not affected by the transfer.

Reverse Shoulder Arthroplasty With Humeral Lateralization Improves Active External Rotation in Patients With Fatty Infiltration of Infraspinatus and Teres Minor

Reverse Shoulder Arthroplasty With Humeral Lateralization Improves Active External Rotation in Patients With Fatty Infiltration of Infraspinatus and Teres Minor

Clinical results of bony increased-offset reverse shoulder arthroplasty (BIO-RSA) associated with an onlay 145° curved stem in patients with cuff tear arthropathy: a comparative study

The main limits of the Grammont design reverse shoulder arthroplasty (RSA) are loss of external rotation and scapular notching. They can be addressed with glenoid or humeral lateralization. The aim of the study was to compare outcomes of lateralized bony increased-offset RSA (BIO-RSA) vs. standard RSA in patients with an onlay 145° curved stem. A comparative cohort study of 29 standard RSAs and 30 BIO-RSAs was performed. At 2 years postoperatively, Constant score, American Shoulder and Elbow Surgeons score, visual analog scale score, range of motion, and radiographs were evaluated. After comparison between the groups, patients were analyzed considering patients younger and older than 65 years. All parameters significantly improved after surgery in both groups. Postoperatively, the 2 groups did not show any clinical and radiographic differences (P > .05). In patients <66 years, BIO-RSA showed a significantly higher value of external rotation (49° ± 12° vs. 30° ± 19° [P = .025], elbow at side; 81° ± 17° vs. 56° ± 22° [P = .016], elbow at 90° of abduction)and a positive trend for all other parameters (P > .05). In patients >65 years, standard technique showed a positive trend for all the parameters (P > .05). No other significant differences were found. At 2 years of follow-up, the use of standard RSA or BIO-RSA in an implant with an onlay 145° curved stem provided similar outcomes. The humeral lateralization alone is sufficient to decrease notching and to improve external rotation. BIO-RSA increases external rotation in patients between 50 and 65 years old. Glenoid bone graft in RSA has a high incorporation rate (completed in 90%).

Lower Trapezius Transfer to Improve External Shoulder Rotation in Patients With Brachial Plexus Injury

Introduction: Adult brachial plexus injury is characterized by many complex problems and remains a dilemma to a reconstructive micro-surgeon. The majority of reported papers focus to improve or restore shoulder abduction. Attempts to improve external rotation through tendon transfer has been reported earlier only in the pediatric population. Recently, a novel technique of lower trapezius transfer to improve shoulder external rotation in the adult patients with brachial plexus injury has been reported with encouraging results. Objective: First, we aimed to compare the shoulder external rotation improvement through the lower trapezius transfer. Second, we evaluated the increase in shoulder and elbow joint motion, the transfer impact related to life quality, and muscle strength. Materials and Methods: At our institution, between 2011 and 2013, 10 lower trapezius transfers were performed. All patients were evaluated by means of Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and shoulder and elbow arc of movement goniometry, and they were classified according to Mallet (evaluation of function and arm appearance) and Lovett Scale (muscle strength grading). Results: Mean follow-up time was 6 months. There was a significant improvement in shoulder active flexion ( P = .046) and abduction ( P = .026), and external rotation improvement of 17° on active motion and 14° on passive one. In terms of shoulder abduction, the mean upsurge was 13° to active motion and 14° to passive. DASH score showed statistically significant improvement ( P = .008). Discussion and Conclusion: The main indication of lower trapezius transfer is the complete loss of shoulder external rotation in patients with brachial plexus or other neurologic injuries. This study showed an improvement in shoulder flexion and abduction, which have an impact on life quality measured by DASH score. Having seen that, we strongly believe that lower trapezius transfers could be performed to improve the shoulder stability and as a consequence, improve patient’s life quality.

Effect of General Anesthesia on Preoperative Hip Range of Motion in Patients Undergoing Hip Arthroscopy.

The purpose of this study was to investigate the effect of general anesthesia on preoperative passive hip range of motion (ROM) in patients undergoing hip arthroscopy for various indications. A total of 260 consecutive patients undergoing hip arthroscopy were included in this study. Passive hip ROM was evaluated bilaterally in the clinic and subsequently under general anesthesia immediately preoperatively. Demographic variables, including age, height, weight, and clinical diagnosis, were recorded for all patients. Hips with pincer-type femoroacetabular impingement (FAI) and hips with acetabular dysplasia showed a mean increase of 4° and 6°, respectively, in hip external rotation at 90° of hip flexion (ER-90) with induction of anesthesia (P=.018 and P=.021, respectively). In contrast, a statistically significant reduction in hip abduction (2°) and hip flexion (4°) was observed following induction of anesthesia in healthy contralateral hips of patients presenting with unilateral hip pathology (P=.01 and P<.001, respectively). Hip ROM does not change to a clinically significant extent with induction of general anesthesia. Small increases in external rotation in patients with FAI or acetabular dysplasia are within the standard error for ROM measurements. [Orthopedics. 2016; 39(6):e1165-e1169.].

Contralateral Trapezius Transfer to Restore Shoulder External Rotation Following Adult Brachial Plexus Injury

To evaluate the outcome of contralateral lower trapezius origin transfer (CLTOT) to restore shoulder external rotation in patients with shoulder paralysis after brachial plexus injury (BPI). We evaluated 12 patients with a history of BPI with persistent shoulder paralysis. All patients had compromised ipsilateral lower trapezius muscle function. All patients underwent CLTOT prolonged with lumbar fascia to the affected infraspinatus tendon either isolated (7patients) or as part of multiple tendon transfer (5 patients). Standardized patient outcomes measures were obtained. At 23 months' follow-up, 10 patients had improved shoulder external rotation from no motion preoperatively to an average external rotation 110° from the abdomen. Five patients had marked improvement of pain, including 2 with isolated CLTOT and 3 with additional tendon transfers. Two patients experienced no change in pain. There were noted improvements in the Constant shoulder scores, simple shoulder value, and Disabilities of the Arm, Shoulder, and Hand scores. One patient sustained a fall resulting in stretch injury to the transfer, underwent successful revision surgery, and regained 100° active shoulder external rotation away from the abdomen more than a year after revision surgery. Another patient's transfer failed during rehabilitation but the patient elected not to pursue treatment. No patients had changes in contralateral shoulder motion or strength or any pain from the contralateral shoulder. This study demonstrated that CLTOT to the infraspinatus tendon was effective in improving shoulder external rotation in patients with BPI. Therapeutic IV.

Selective Neurotization of the Infraspinatus Muscle in Brachial Plexus Birth Injury Patients Using the Accessory Nerve.

The authors present a new technique to improve active shoulder external rotation in patients with brachial plexus birth injury. Eight brachial plexus birth injury patients (aged 1.5 to 4.7 years) lacking active external rotation in adduction (<10 degrees) with congruent glenohumeral joints and no significant internal rotation contracture (passive external rotation >45 degrees) underwent neurotization of the infraspinatus branch of the suprascapular nerve with the spinal accessory nerve. Active and passive range of shoulder motion was measured postoperatively (3, 6, and 12 months). Parents' satisfaction was assessed. At 1-year follow-up, mean improvement for active external rotation was 47 degrees (range, 20 to 85 degrees) in adduction and 49 degrees (range, 5 to 85 degrees) in abduction. All but one patient's parents were satisfied. Functionally significant active external rotation can be restored in brachial plexus birth injury by direct neurotization of the infraspinatus muscle.

Movilización posterior glenohumeral versus tratamiento kinésico convencional en la capsulitis adhesiva primaria: ensayo clínico aleatorizado

To compare the short-term efficacy of a glenohumeral posterior mobilization technique versus conventional physiotherapy for the improvement of the range of external rotation in patients with primary adhesive capsulitis of the shoulder. This is a randomized clinical trial conducted at Hospital Clinico San Borja Arriaran in Chile. Fifty-seven patients with an age range of 50 to 58 years old were enrolled in two groups. Both groups were randomized to receive a treatment of 10 sessions: the experimental group (n=29) received a glenohumeral posterior mobilization technique after training with a cycle ergometer, and the control group (n=28) received conventional physiotherapy. The primary outcome measure was range of passive movement in external rotation; secondary outcomes were forward flexion and shoulder abduction, pain perception using the visual analogue scale and functionality test using the Constant-Murley Score. The study had the statistical power to detect a difference of four degrees between the groups in the improvement of the range of external rotation at the end of the treatment period. The experimental group showed a significant improvement with a mean difference of 46.3 degrees (SD=8.7) compared to 18.1 (SD=7.2) in the control group (p<0.0001). There was also a decrease in the perception of pain (p= 0.0002) and improved function (p< 0.0001) in the group treated with glenohumeral posterior mobilization technique. The glenohumeral posterior mobilization technique applied after training with cycle ergometer is an effective short-term technique to treat primary adhesive capsulitis decreasing the severity of pain and improving joint function compared with conventional physiotherapy treatment. The degree of increase in shoulder external rotation is more than 20 degrees beyond the increase achieved with conventional treatment.

Clinical performance of lateralized versus non-lateralized reverse shoulder arthroplasty: a prospective randomized study

Reverse shoulder arthroplasty (RSA) is an established therapeutic option in the treatment of cuff tear arthropathy (CTA). Recent studies have described a positive effect of lateralization of the center of rotation, especially on postoperative rotational function. The goal of this study is to compare the outcome of non-lateralized versus lateralized RSA with particular regard to rotational function in patients with CTA. Thirty-four patients underwent implantation of RSA either with lateralization (n=17) or without lateralization (n=17) by use of a 1-cm autologous bone graft ("bony increased offset") of the humeral head for CTA. Clinical outcomes were measured with the Constant score; the Disabilities of the Arm, Shoulder and Hand score; and the Activities of Daily Living RequiringExternal Rotation score, as well as measurement of external rotation and determination of the external rotation lag sign with the arm at the side and at 90° of abduction, at 1 year postoperatively and at final follow-up. Computed tomography scan evaluation was performed in all patients preoperatively and at 1 year postoperatively to assess preoperative fatty infiltration of the rotator cuff and bony integration of the graft postoperatively. At final follow-up, all patients showed significantly increased functional results. There were no significant differences in the evaluated parameters. If patients with degenerative changes of the teres minor were excluded, the lateralized group showed significantly increased external rotation. Bony integration of the graft could be verified on postoperative computed tomography scans in all patients. RSA with bony lateralization shows a trend toward improved external rotation in lateralized RSA, with a statistically significant improvement in external rotation in patients with an intact teres minor.

Nerve Transfers for Shoulder Function for Traumatic Brachial Plexus Injuries

The objective of this article was to evaluate the clinical results of nerve transfer procedures for the restoration of shoulder abduction and external rotation in patients with traumatic brachial plexus injuries. A retrospective study was done to determine the results of nerve transfers for shoulder function in patients with traumatic brachial plexus injuries. The authors evaluated shoulder abduction and external rotation in terms of type of nerve transfer performed (single vs. double) and the time delay to surgery (greater or less than 6 mo). A total of 20 patients were evaluated with 5 patients having double nerve transfers and 15 patients having single nerve transfers to restore shoulder function. All surgeries were done within 12 months of injury. The average follow-up for the 20 patients was 28.4 ± 17.5 months (minimum of 12 mo follow-up for all patients). The mean shoulder abduction and external rotation for the single nerve transfer group was 71.3 ± 48 degrees and 56 ± 44 degrees, respectively. For the double nerve transfer group, the mean shoulder abduction and external rotation was 123 ± 49 degrees and 86 ± 35 degrees, respectively. The difference was significant for the shoulder abduction (p = 0.05) but not for the external rotation (p = 0.19). In terms of time delay to surgery, there was no difference between surgery done in 6 months or less versus those done greater than 6 months but less than 12 months for shoulder abduction (88.1 ± 47.7 degrees and 77.1 ± 63.4 degrees, respectively, p = 0.67) and shoulder external rotation (63.8 ± 42.2 degrees and 62.8 ± 49.3 degrees, respectively, p = 0.96). The results of this study showed that nerve transfers can restore functional shoulder abduction and external rotation. Double nerve transfers tend to have significantly greater range of shoulder abduction compared with single nerve transfers if done within 1 year of injury.

Eccentric hip abductor weakness in patients with symptomatic external snapping hip

Symptomatic external snapping hip can be a long-standing condition affecting physical function in younger people between 15-40 years. Gluteal weakness has been suggested to be associated with the condition. The aim of this study was to investigate whether eccentric hip abduction strength is decreased in patients with external snapping hip compared with healthy matched controls, and to examine isometric hip abduction, adduction, extension, flexion, internal rotation, and external rotation in patients with external snapping hip and matched controls. Thirteen patients with external snapping hip were compared with 13 healthy matched controls in a cross-sectional study design. The mean age of the patients was 25.5 ± 3.4 years and the mean age of the controls was 25.6 ± 2.6 years. Eccentric and isometric strength were assessed with a handheld dynamometer, using reliable test procedures. Eccentric hip abduction strength was 16% lower in patients with external snapping hip compared with healthy matched controls (1.50 ± 0.47 Nm/kg versus 1.82 ± 0.48 Nm/kg, P = 0.01). No other strength differences were measured between patients and controls (P > 0.05). Eccentric hip abductor weakness was present in patients with symptomatic external snapping hip compared with healthy matched controls.

Two-stage Reimplantation for Treating Prosthetic Shoulder Infections

Two-stage reimplantation for prosthetic joint infection reportedly has the lowest risk for recurrent infection. Most studies to date have evaluated revision surgery for infection using an anatomic prosthetic. As compared with anatomic prostheses, reverse total shoulder arthroplasty is reported to have a higher rate of infection. We determined reinfection rates, functional improvement, types and rates of complications, and influence of rotator cuff tissue on function for two-stage reimplantation for prosthetic joint infection treated with reverse shoulder arthroplasty. We retrospectively reviewed 27 patients treated with a two-stage reimplantation for prosthetic shoulder infection using a uniform protocol for management of infection; of these, 17 had reverse shoulder arthroplasty at second-stage surgery. Types of organisms cultured, recurrence rates, complications, function, and radiographic followup were reviewed for all patients. One of the 17 patients had recurrence of infection. The mean (± SD) Penn shoulder scores for patients treated with reverse shoulder arthroplasty improved from 24.9 ± 22.3 to 66.4 ± 20.8. The average motion at last followup was 123° ± 33° of forward flexion and 26° ± 8° of external rotation in patients treated with a reverse shoulder arthroplasty. The major complication rate was 35% in reverse shoulder arthroplasty, with five dislocations and one reinfection. There was no difference in final Penn score between patients with and without external rotation weakness. Shoulder function and pain improved in patients treated with a second-stage reimplantation of a reverse prosthesis and the reinfection rate was low. Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Our Experience with Secondary Reconstruction of External Rotation in Obstetrical Brachial Plexus Palsy

Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy. From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed. There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees). Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

Lengthening of subscapularis and transfer of the lower trapezius in the correction of recurrent internal rotation contracture following obstetric brachial plexus palsy

An internal rotation contracture is a common complication of obstetric brachial plexus palsy. We describe the operative treatment of seven children with a recurrent internal rotation contracture of the shoulder following earlier corrective surgery which included subscapularis slide and latissimus dorsi transfer. We performed z-lengthening of the tendon of the subscapularis muscle and transferred the lower trapezius muscle to the infraspinatus tendon. Two years postoperatively the mean gain in active external rotation was 47.1 degrees, which increased to 54.3 degrees at four years. Lengthening of the tendon of subcapularis and lower trapezius transfer to infraspinatus improved the range of active external rotation in patients who had previously had surgery for an internal rotation contracture.

Positional Stretching of the Coracohumeral Ligament on a Patient with Adhesive Capsulitis: A Case Report

Idiopathic frozen shoulder is a common medical diagnosis for patients seeking physical therapy. Radiographic and surgical evidence exists that describes the coracohumeral ligament (CHL) as a major contributor to lack of external rotation in patients diagnosed with frozen shoulder. No stretching techniques targeting the anatomical fiber orientation of the CHL have been reported in the literature. This single-patient case-report describes the use of a positional stretching technique of the CHL on a 51-year-old female diagnosed with phase I frozen shoulder. The patient completed 8 in-office visits and 17 home exercise program sessions of positional CHL stretching combined with a simple volitional rotator cuff exercise program in a 4-week period. The patient's Disabilities of the Arm Shoulder and hand (DASH) scores improved from 65 to 36 and Shoulder Pain and Disability Index (SPADI) scores improved from 72 to 8 and passive external rotation from 20° to 71°. While a cause-and-effect relationship cannot be inferred from a single case, this report may foster further investigation regarding the role of the CHL in patients with stage- I and stage- II frozen shoulder as well as therapeutic strategies to help reduce loss of mobility and function.