Mean ASES Score Research Articles

Arthroscopic Management of Glenoid and Greater Tuberosity Bipolar Fractures.

ObjectiveTo report the clinical and radiological outcomes of arthroscopically assisted surgery for combination of glenoid and greater tuberosity fractures after traumatic shoulder dislocation.MethodsFrom December 2013 to December 2018, patients with concomitant fracture of the greater tuberosity and glenoid who underwent arthroscopically assisted surgery were retrospectively reviewed. Fifteen patients were included. Preoperative computed tomography (CT) scans with 3D reconstruction were performed to evaluate the fracture configuration and associated fractures. All patients underwent arthroscopically assisted surgery under general anesthesia with brachial plexus anesthesia in the lateral position. Under the arthroscopic approach, a comprehensive inspection of the joints was firstly conducted to examine the injury of bones and other tissues. With arthroscopy support, closed reduction and internal fixation of both fractures were performed with suture anchors, with or without additional cannulated screws. At the same time, other injuries were also repaired under the arthroscope. Patients were followed up (6 weeks，8 weeks，3 months，6 months，1 year after surgery) regularly for at least 1 year. At the follow‐up, clinical outcomes (Constant score, ASES score, range of motion, and VAS score) and radiological outcomes were analyzed.ResultsOf the 15 patients, there are seven cases of men, eight cases of women; aged 22–66 years, with an average age of 48 years; left shoulder for five cases, 10 cases of the right shoulder. The injury mechanisms were: a simple fall (n = 9), an epileptic seizure (n = 1), a high fall injury (n = 2), and a traffic accident (n = 3). Of the 15 cases of glenoid fracture, 11 cases were type Ia and four cases were type II according to the Ideberg Classification System. The mean size of the glenoid fracture fragment was 28.4% (range, 8.7%–47.2%). According to the Mutch classification system, the fractures of the greater tuberosity were divided into: five cases of avulsion, one case of compression, and nine cases of split. Average time of follow‐up was 38.2 months (range, 12–70 months), and one case was lost to follow‐up. With fractures healing well, almost all patients had a good joint function. At the final follow‐up, mean anterior flexion was 157°; mean external rotation was 40°; mean internal rotation was T11 level; the mean Constant–Murley score was 94.6 points (range, 70–100 points); the mean ASES score was 94.6 points (range, 79–100 points); and the mean VAS score was 0.4 points (range, 0–2 points). No recurrent instability or re‐dislocation occurred. No patient had revision surgery.ConclusionArthroscopic management of glenoid and greater tuberosity bipolar fractures was useful and effective with minimal injury, and it achieved satisfactory clinical and radiological outcomes at a mean follow‐up time of more than 3 years.

Treatment effects of reverse total shoulder arthroplasty \u2013 a simple method to measure outcomes at 6, 12, 24 and 60\u2009months for each patient

BackgroundAlthough shoulder arthroplasty is less common than knee or hip arthroplasty, the number of procedures being performed is increasing rapidly. The treatment effect is a simple method to measure outcome of joint replacement. The method was applied to measure results of total hip/knee arthroplasty but not yet for shoulder arthroplasty.MethodsIncluded were patients with unilateral cuff arthropathy (Hamada grades > = 2) treated with reversed total shoulder arthroplasty (RSA) in this prospective multicenter study. The patients were assessed with the ASES questionnaire. The treatment effects (TE) was calculated for each patient. TE = score reduction/baseline score. A positive TE means amelioration, TE = 0 unchanged, and a negative TE means worse. The primary aim was to calculate the TE’s for RSA at 6, 12, 24, and 60 months postoperatively. The secondary aim was to analyze the influence of confounders (preoperative Hamada grade, age, gender, dominance, side of the affected shoulder, general co-morbidities measured using ASA grade).ResultsTwo hundred three patients were included for this analysis of whom 183 patients had a complete 2 year follow up. Two years postoperatively the mean ASES score augmented significant from 20.5 to 78.7 (p < 0.001). The 2 year TE’s ranged from 1 to 0.09. We had no patient with a negative TE. A higher Hamada grade was associated with better TE’s (Hamada grade 4+ vs. 2, p-value 0.042). For age and dominant side there were weak associations where those aged 80+ and dominant side had better TE’s. The patients with higher ASA grade had lower TE’s (ASA grade 4+ vs. 1, p-value 0.013). The mean TE’s were 0.77 at 6-months, 0.81 at 1 year, 0.76 at 2 years and 0.73 at 5 years.ConclusionsThe outcome for reverse shoulder arthroplasty can be measured with the treatment effect method; the 2 years TE’s vary from 1 to 0.09. The mean treatment effects change little in the first five postoperative years (from 0.73 to 0.81). The confounders for better TE’s were: higher severity of cuff arthropathy (Hamada grade 3, 4 and 5), less co-morbidities (ASA Grade 1), higher age (80+) and dominant side. Gender did not influence the 2-year TE’s.Trial registrationComité intercantonal d’éthique (Jura, Fribourg, Neuchâtel), number 01/2008, 24.09.2008.

Minimum 2-year clinical outcomes after superior capsule reconstruction compared with reverse total shoulder arthroplasty for the treatment of irreparable posterosuperior rotator cuff tears in patients younger than 70 years

To compare clinical outcomes following arthroscopic superior capsule reconstruction (SCR) using a dermal allograft (DA) with reverse total shoulder arthroplasty (RTSA) when used to treat irreparable posterosuperior rotator cuff tears without glenohumeral osteoarthritis (GHOA) in patients younger than 70 years. In this case-control study, patients who underwent SCR or RTSA for the treatment of irreparable posterosuperior rotator cuff tears, who were younger than 70 years at the time of surgery, and who were at least 2 years out of surgery were included. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numerical Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores and the 12-Item Short Form Health Survey (SF-12). Return to sports and patient satisfaction along with clinical failures (recurrent pain or persistent pain or loss of function), revisions, and complications were reported. Two-year follow-up was obtained on 22/22 patients (100%) in the SCR group and 29/33 patients (88%) in the RTSA group. Group differences were significant for age (SCR mean, 57 ± 6.6 years, vs. RTSA mean, 63 ± 4.9 years; P < .001) and follow-up interval (SCR mean, 2.1 years, vs. RTSA mean, 2.9 years; P = .001). Preoperative outcome scores showed no significant differences (all P > .05) between groups. No significant differences in postoperative outcome scores were detected (P > .05) between SCR and RTSA: the mean ASES score was 82.6 ± 15.5 vs. 79.3 ± 21.4, mean SANE score was 71.4 ± 24.5 vs. 75.4 ± 23.3, mean QuickDASH score was 16.2 ± 16.9 vs. 25.3 ± 21.0, and mean SF-12 was 47.7 ± 8.8 vs. 46.9 ± 10.4. No significant differences in return-to-sport responses were noticed between groups at baseline or postoperatively (P = .585, P = .758). One SCR was revised at 1.2 years with revision SCR and 1 RTSA had the glenoid component revised day 1 postoperatively for instability. Both patientgroups achieved successful clinical outcomes. SCR using DA results in similar postoperative functional outcomes in a younger patient population when compared to RTSA for the treatment of irreparable posterosuperior rotator cuff tears, without GHOA, at short-term follow-up.

Clinical midterm results of arthroscopic rotator cuff repair in patients older than 75 years

The effect of patient age on functional improvement after arthroscopic rotator cuff repair (ARCR) is still a matter of debate. The purpose of this study was to evaluate the clinical midterm results after ARCR in patients who were 75 years or older at the time of surgery. A total of 31 shoulders in 30 patients older than 75 years at the time of surgery underwent ARCR for a degenerative full-thickness rotator cuff tear (RCT) between 2010 and 2016. Among those, 23 shoulders in 22 patients (74%) with a mean age at time of surgery of 77 ± 2 years (range, 75-82 years) were followed up after a mean of 7 ± 2 years (range, 3-9 years). Clinical assessment included the Western Ontario Rotator Cuff (WORC) index as well as patient satisfaction, the Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score. Overall, patient satisfaction was excellent, as everybody stated to be very satisfied with the surgery. Neither any complication nor revision surgery occurred during the study period. At final follow-up, the mean WORC index was 88% ± 15%. The mean SSV was comparable between the affected shoulder (90% ± 15%) and the contralateral side (87% ± 15%) (P = .235). The mean SST score was 10 ± 2 points and the mean ASES score was 89 ± 17 points. ARCR for symptomatic RCTs without advanced muscle degeneration in patients older than 75 years at the time of surgery provided good clinical results and high patient satisfaction at midterm follow-up.

Simultaneous removal of a locking plate and implantation of a reversed shoulder prosthesis in elderly patients suffering from fracture sequelae of the proximal humerus.

Open reduction and internal fixation with a locking plate are performed frequently to treat fractures of the proximal humerus. Avascular necrosis and non-union or malunion are potential complications of this procedure, which lead to specific fracture sequelae. The aim of this study was to investigate the clinical and radiological results of patients treated by removal of a failed locking plate of the proximal humerus and simultaneous implantation of a reverse total shoulder prosthesis. Twenty-one patients (f = 17, m = 4; mean age 70years) out of 29 patients were available for follow-up after a mean period of 45 (30-65) months. At follow-up, all patients were assessed with the constant score and the ASES score as well as plain radiographs. In comparison with the preoperative values, abduction (31° vs. 115°; p < 0.001) and forward flexion (34° vs. 121°; p < 0.001) improved until follow-up, while the pain score on a visual analog scale decreased (6.7 vs. 0.9; p < 0.001). At follow-up, the mean ASES score rated 73 and the constant score rated 62. The radiologic findings included scapular notching (n = 7; 33%), radiolucency (n = 4; 19%), heterotopic ossifications (n = 3; 14%), and stress shielding (n = 4; 19%). Reverse total shoulder arthroplasty is a useful instrument for the treatment of failed locking plate osteosynthesis of the proximal humerus in elderly patients. The patients benefit from both pain relief and improved shoulder function. The rate of radiologic changes like scapular notching, radiolucency, stress-shielding and heterotopic ossifications at follow-up is notable.

Efficiency of local hyaluronic acid injections in subacromial impingement syndrome

Chronic shoulder pain associated with subacromial impingement syndrome (SIS) is a common pathology that causes suffering and disability. One of the treatments for SIS is the local injection of hyaluronic acid (HA) preparations.Objective:to evaluate the efficiency of subacromial injection of HA in chronic shoulder pain associated with SIS.Subjects and methods.A study group consisted of 31 patients (48.4% of women and 51.6% of men; mean age 53.8±15.2 years) with chronic shoulder pain (&gt;3 months) that had occurred after rotator tendon injury confirmed by ultrasound and/or magnetic resonance imaging. All the patients received two subacromial injections of 40 mg HA in 2 ml at a 7-day interval. The efficacy criteria were the changes of pain during movement (100-mm visual analogue scale (VAS)) and functional ability according to the ASES and CSC questionnaires at 1, 3 and 6 months.Results and discussion.During the treatment, there was a considerable improvement in all measures. At baseline and 1, 3, and 6 months, the mean pain severity measured on VAS was 60.0±20.0, 40.0±25.4, 31.6±26.0, and 32.2±26.5 mm (p&lt;0.001), the mean ASES scores were 53.64±16.43, 70.08±17.70, 86.13±12.86, and 82.69±27.88 (p&lt;0.001); the mean CSC scores were 52.38±21.1, 66.26±20.83, 73.9±24.14, and 76.1±25.02 (p&lt;0.001) respectively. No serious adverse events were noted.Conclusion.Subacromial injection of HA is an effective and safe treatment for chronic shoulder pain associated with SIS.

Prospective Randomized Trial Of Biologic Augmentation With Mesenchymal Stem Cells In Patientsundergoing Arthroscopic Rotator Cuff Repair

Objectives: To compare the clinical outcome of arthroscopic rotator cuff repair with and without augmentation with MSCs and to identify the incidence of persistent structural defects in the tendon following surgery Methods: Patients aged 18-70 undergoing repair of a full-thickness supraspinatus tear or partial thickness converted to full thickness tear determined by MRI were identified and prospectively enrolled. Exclusion criteria included involvement of the subscapularis tendon, revision surgery or irreparable tear. In the injection group, 60 cc of bone marrow aspirate was drawn from the iliac crest and processed to bone marrow aspirate concentrate (BMAC) using the Arthrex Angel System (Arthrex, Naples, FL). After completion of the rotator cuff repair, half of the BMAC was injected into the tendon at the junction of the bone and tendon while the other half was injected at the site of the footprint. The control group received a small 0.5 cm incision on the hip to maintain blinding. All patients underwent a shoulder exam pre-operatively as well as at 3 months, 6 months, 1 year and 2 years post-operatively. All patients completed the Standardized Shoulder Test (SST), ASES, Constant, SANE, and VR/SF-12 questionnaires preoperatively as well as 3 months, 6 months, 12 months, 18 months and 24 months postoperatively. Baseline questionnaire scores were subtracted from scores at each timepoint to find the improvement and unpaired T-tests were performed between the two groups. Additionally, all patients underwent an MRI at 12 months postoperatively to evaluate the rotator cuff. MRIs were read by a board-certified orthopaedic surgeon and graded using the Sugaya classification system. Results: 34 patients were randomized to the control group and 28 were randomized to the receive the injection. Average BMA MSC concentration (#/uL) was 2.63 compared to 14.95 for the BMAC MSC concentration. As a result, the BMAC was on average 5.68 times as concentrated with respect to MSC per ul when compared to the BMA. Patients received an average BMAC volume of 2.7 mL, equating to 50410.79 +/- 25375.45 mesenchymal stem cells. There were no differences across improvement in patient reported outcomes from baseline between the control group and the group randomized to receive the injection, except for the Standardized Shoulder Test at 6 months. The mean SST score at 12 months was 87.50 in the BMAC group compared with 85.32 in the control (p=0.18). The mean ASES score at 12 months was 87.38 in the BMAC group and 89.96 in the control group (0.67). Mean Sugaya score for the control group was 3.25±1.12 (range 2-5). Mean Sugaya score for the injection group was 2.60±0.91 (range 2-5). Sugaya scores showed statistical significance with Chi-squared test at 1 year postoperative MRI (p=0.0012), and approached statistical significance with independent t test (p=0.067). Conclusion: MSCs injected into the shoulder at the time of rotator cuff repair show improved tendon quality on post-operative MRI at 1-year post-op, based on the Sugaya scoring system, with the difference in mean Sugaya score approaching significance. Further investigation is needed into this new and evolving treatment; however, it shows promise for improving the rate of rotator cuff repair healing and overall functional outcome.

Displaced isolated greater tuberosity fractures of elder adults treated with plate osteosynthesis.

We elucidated the effect of open reduction and internal fixation with locking plate for acute isolated displaced greater tuberosity fractures of humerus in elder adults (aged >60 years). From 2009 to 2015, data from 32 patients, aged between 60 and 88 years, who had acute unilaterally displaced greater tuberosity fractures of humerus were collected and evaluated retrospectively. All the fractures were managed with open reduction and internal fixation with locking plate. The follow-up period was 50.8 months on an average (range 22-80 months). Finally, 25 patients were available for final evaluation of radiographic and functional results. All the 32 fractures had union with the average union time of 14 weeks (range 10-18 weeks) and with no complications. The average of preoperative Visual Analogue Scale (VAS) was 6.2 (range 4-8), ASES was 30.4 (range 13-45), and Constant score was 30.4 (range 20-45). At the last follow-up, the mean VAS was 1.3 (range 0-2.5), the mean ASES score was 90.1 (range 72-100), and the mean Constant score was 90.3 (range 80-100). There were statistically significant differences between preoperative and final follow-up in VAS, ASES, and Constant score. Hundred percent of patients had good or excellent results by Constant score, with excellent results (86-100) in 17 (68%) patients and good result (71-85) in 8 (32%). In conclusion, open reduction and internal fixation with locking plate is an effective treatment for acute displaced greater tuberosity fractures of humerus in elder adults.

Intramedullary nailing versus plating in shaft humerus fractures: a prospective randomized study

&lt;p&gt;Introduction- The two most commonly used modalities of internal fixation in fracture shaft of humerus are Plate osteosynthesis and Intramedullary nailing. The present study aims to analyze and compare both the techniques in terms of functional and radiological outcome. Material and Methods- 43 patients with diaphyseal fracture humerus were treated with Intramedullary nailing and plating between March 2015 and March 2016. The inclusion criteria were patients with closed diaphyseal fracture humerus. Compound fractures, pathological fractures, Non-union, mal-union fractures were excluded from the study. Results- 22 (51.2%) cases were operated using the antegrade nailing technique whereas dynamic compression plating was done in 21 (48.8%) cases. The mean age was 42±4.2 years. Road traffic accident was the most common mechanism of injury with 29 (67.5%) cases. 12-A2 type of fracture pattern were most common involving 23 (53.5%) cases. The mean surgical time was 68 mins in cases where nailing was done and 115 mins in cases with plating (P&amp;lt;0.001). Radiological union was seen at 13±4.8 weeks and 15±3.9 weeks in the nailing and plating group respectively. There were 2 (9.09%) cases in the nailing group and 1 (4.7%) case in the plating group which had delayed union. 3 (13.6%) cases in the nailing group had post-operative shoulder stiffness. The mean ASES score at the end of one year was 31.3 in nailing and&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;The two most commonly used modalities of internal fixation in fracture shaft of humerus are plate osteosynthesis and intramedullary nailing. The present study aims to analyze and compare both the techniques in terms of functional and radiological outcome.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;43 patients with diaphyseal fracture humerus were treated with Intramedullary nailing and plating between March 2015 and March 2016. The inclusion criteria were patients with closed diaphyseal fracture humerus. Compound fractures, pathological fractures, non-union, mal-union fractures were excluded from the study&lt;/span&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;22 (51.2%) cases were operated using the antegrade nailing technique whereas dynamic compression plating was done in 21 (48.8%) cases. The mean age was 42±4.2 years. Road traffic accident was the most common mechanism of injury with 29 (67.5%) cases. 12 A2 type of fracture pattern were most common involving 23 (53.5%) cases. The mean surgical time was 68 minutes in cases where nailing was done and 115 minutes in cases with plating (P &amp;lt;0.001). Radiological union was seen at 13±4.8 weeks and 15±3.9 weeks in the nailing and plating group respectively. There were 2 (9.09%) cases in the nailing group and 1 (4.7%) case in the plating group which had delayed union. 3 (13.6%) cases in the nailing group had post-operative shoulder stiffness. The mean ASES score at the end of one year was 31.3 in nailing and 29.6 in plating group (P =0.327). There were 37 (86.5%) cases with excellent to good results. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Nailing and plating have equal functional outcomes in cases with shaft humerus fracture.&lt;/span&gt;&lt;/p&gt;&lt;p&gt;29.6 in plating group (P=0.327). There were 37 (86.5%) cases with excellent to good results. Conclusion- Nailing and plating have equal functional outcomes in cases with shaft humerus fracture.&lt;/p&gt;

Functional outcome of arthroscopic repair of full-thickness degenerative rotator cuff tears

BackgroundIn the past decade, in spite of the advancement in the clinical knowledge, imaging modalities for precise diagnosis and minimally invasive surgeries, the ideal management for degenerative rotator cuff tears is still a matter of debate. MethodsThis prospective study was conducted from January 2013 to August 2016, involved 16 patients (09 males, 07 females) with the mean age of 62.81±7.24 years (range 54–80 years), who had the full-thickness degenerative tear of the rotator cuff. Arthroscopic repair using single row technique was performed in all the patients. The outcome was assessed using ASES questionnaire; pain score by visual analogue scale (VAS) and range of motion of the shoulder joint at presentation, 24 weeks and at final follow-up. ResultsAt the mean follow-up of 24.68±3.17 months (range 20–29 months), the mean ASES score and pain score (VAS) improved significantly from 31.16±5.57 to 71.79±3.92 (p-value <0.001) and 5.63±0.72 to 1.9±0.92 (p-value <0.001) respectively. There was significant improvement in all the movements of the shoulder joint. 14 patients were satisfied with the final functional outcome. ConclusionArthroscopic repair of a full thickness degenerative tear of the rotator cuff using single row repair technique leads to satisfactory functional outcome in terms of activities of daily living, pain scores and range of motion.

Importance of additional temporary pin fixation combined coracoclavicular augmentation using a suture button device for acute acromioclavicular joint dislocation.

We evaluated the outcomes of coracoclavicular (CC) augmentation using a suture button device with additional temporary pin fixation for acute acromioclavicular (AC) joint dislocation. Thirty-six consecutive cases who underwent CC augmentation using TightRope™ (Arthrex, Naples, FL, USA) were included. We temporarily fixed trans-articular pins in the first 10 cases (TA group) and a trans-spine pin in the next 26 cases (TS group). The radiological and clinical outcomes were evaluated at minimum 2years postoperatively. The mean follow-up period was 56.7months (range, 24-84months). At the final follow-up evaluation, reduction status showed anatomical reduction in 25 cases (69.4%), slight loss of reduction in seven cases (19.4%), partial loss of reduction in two cases (5.6%), and total loss of reduction in two cases (5.6%). The mean ASES score, UCLA score, and subjective shoulder value were 92.3, 32.9, and 91.6%, respectively. There were no significant differences between the two groups with respect to the outcomes. Intraoperative complications occurred in three cases (8.3%) including two cases of failed reduction and one case of technical failure of the implant. Postoperative complications occurred in three cases (8.3%) including one case of pin tract infection and distal clavicle fracture at the clavicle-hole, one case of reduction loss by severe subsidence of the clavicular button, and one case of shoulder stiffness. CC augmentation using a suture button device with temporary pin fixation yielded satisfactory radiological and clinical outcomes. These results support that temporary pin fixation for the AC joint may help to protect the AC reduction in the early phase of healing and rigid scar formation when performing CC fixation using a suture button device. Level-IV, Retrospective Case Series, Treatment Study.

No-holes transpectoral tenodesis technique vs tenotomy of the long head of the biceps brachii.

There is no univocal consensus regarding Long Head of the Biceps (LHB) best treatment between tenotomy and tenodesis. There is no consensus regarding the best location to perform the tenodesis. The LHB tenodesis performed by the proximal tendon excision as first step can miss the proper tension to the muscle belly. Fixations proximal to the pectoralis major can lead to groove pain. This study aims to test the efficacy of a new LHB tenodesis technique by comparing its results with the tenotomy. We retrospectively evaluated patients who underwent surgery between May 2014 and May 2015. The mean follow up was 14.7 months. Sixteen patients underwent mini-open tenodesis to the Pectoralis Major tendon by the use of a resorbable suture (TD group); sixteen underwent tenotomy (TT group). The mean age of the TD group was 54 years; the mean age of the TT group was 56 years. We evaluated pain, subjective perception of the patient of possible aesthetic and strength differences between the two biceps, "Popeye sign", and tests to stimulate the LHB. We administered three evaluation questionnaires: the ASES score, the SPADI score, and the SST. 32 consecutive patients were evaluated. The clinical scores did not record statistically significant differences: the mean ASES score was 92.9 (TD) and 90.8 (TT); the mean SPADI score was 92.5 (TD), and 89.7 (TT); the mean SST was 8.9 (TD), and 8.4 (TT). Compared to the TD group, in the TT group we registered with greater frequency the "Popeye sign" with a P value < 0.05 (9 cases vs 1), and spasms in the biceps muscle belly (5 cases vs 1). All other signs or symptoms evaluated were more frequent in the TT group, except the strength difference perceived by the patient (3 patients in the TT group, and 2 in the TD group). No complications were recorded. This new Long Head of the Biceps (LHB) tenodesis technique is valuable and reliable, and provided better results than tenotomy. IV.

Isolated lesions of the lower subscapularis tendon: diagnosis and management.

Isolated lesions of the caudal portion of the subscapularis (SSC) tendon are rare and have not been subject of major attention in the literature yet. However, these lesions can lead to tremendous impairment of shoulder function. The purpose of the present study was to raise clinician's awareness for these "hidden lesions" and to present the crucial steps for diagnosis and management. Five patients (three men, two women; mean age 40) with traumatic isolated caudal SSC lesion were enrolled in the present study. After clinical and radiological examination, all patients underwent diagnostic arthroscopy and open inferior SSC repair. The results of the clinical and radiological examination were documented along with the intraoperative findings. Post-operative pain level and shoulder function were assessed. In all patients the SSC lesion could be detected clinically. In two patients the caudal SSC tear was diagnosed delayed after initial conservative treatment. Preoperatively, all patients showed restricted active movement of the shoulder with positive clinical tests for the SSC. All SSC lesions could be detected on MR images and identified arthroscopically. After a mean follow-up of 12months, all clinical SSC tests were negative, and the patients have almost regained preinjury shoulder function. The mean post-operative pain score (VAS) was 1 (range 0-1), and the mean ASES score was 93.3 (range 91.6-95). Arthroscopic visualization of the SSC tendon is incomplete rendering caudal SSC tears difficult to detect and easy to overlook. Clinicians' awareness of this pathology along with accurate clinical and radiological examination leads to the correct diagnosis. Open caudal SSC repair provides pain relief and reliable shoulder function after short-term follow-up. IV.

The Effect of Cartilage Injury After Arthroscopic Stabilization for Shoulder Instability.

This study was undertaken to (1) determine the incidence of articular cartilage injuries in patients with instability of the glenohumeral joint, (2) determine whether recurrent dislocations increased the risk of articular damage, and (3) correlate these injuries with postoperative clinical outcomes. A cohort was identified of consecutive patients who underwent diagnostic magnetic resonance imaging and shoulder arthroscopy for glenohumeral instability with documented dislocation or subluxation between 1997 and 2006 at a single institution. Patients with moderate or severe osteoarthritis were excluded. Arthroscopic findings were recorded, including lesion location and Outerbridge grade. The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) was used to assess outcome in 61 patients who were available for follow-up. Outcomes were compared between shoulders with and without articular lesions. A total of 87 shoulders (83 patients) met the inclusion criteria, with 69 (83%) men and 14 (17%) women. Mean age was 26.1 years (range, 18-64 years), and mean follow-up was 36 months (range, 33-39 months). Cartilage injuries were found in 56 shoulders (64%). Previously documented shoulder dislocation requiring closed reduction (P=.046) and the number of discrete dislocations (P=.032) were significant for glenoid injury. A greater number of dislocations was associated with higher-grade lesions of the glenohumeral joint (P<.001). Overall, mean ASES score was 89.6 (range, 37-100). In patients with an articular cartilage lesion, mean ASES score was 90.4 (range, 58-100) compared with 88.1 (range, 37-100) in those without this injury (P=.75). Although clinical outcomes were not significantly affected, further investigation is warranted to establish a relationship between these injuries and longer-term outcomes.

Radiostereometric and Radiographic Analysis of Glenoid Component Motion After Total Shoulder Arthroplasty.

Aseptic glenoid component loosening is a common cause of total shoulder arthroplasty (TSA) failure, but early detection is difficult because pain often appears late and radiolucent lines are of uncertain significance. This study sought to answer the following questions: (1) What types of glenoid component motion may be observed during the first 3 years following implantation?; (2) Is the appearance of radiolucent lines around the glenoid component a reliable indicator of component motion?; and (3) Are clinical outcomes correlated with early glenoid component motion within the first 3 years after TSA? Eleven patients (mean age, 60.6 years) underwent TSA using a cemented, all-polyethylene glenoid component with tantalum bead implantation. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, visual analog scale [VAS] pain score, and range of motion) were compared pre- and postoperatively, and radiolucencies were graded according to the criteria of Lazarus et al. Patients were evaluated using radiostereometric analysis at 6 months and 1, 2, and 3 years postoperatively to measure component micromotion in translation and rotation. At a mean follow-up of 50.2 months, mean ASES score had improved from 30.3 to 81.3 (P<.001), mean VAS pain score had improved from 8 to 1 (P<.001), active forward flexion had improved from 109° to 155° (P=.001), active external rotation had improved from 28° to 54° (P=.003), and internal rotation had improved from the level of the sacrum to L3 (P=.002). Radiolucencies were detected around none of the components at 1 year, 6 components at 2 years, and 5 components at 3 years, and these radiolucencies were mostly found around components that experienced high levels of rotational motion.

Clinical Results Following Non-operative Management for Grade III Acromioclavicular Joint Injuries: Does Eventual Surgery Affect Overall Outcomes?

Objectives:The management of grade III acromioclavicular (AC) joint injuries remains controversial. Good to excellent results have been reported with nonsurgical management; however, some patients report persistent pain related to the AC joint following non-operative treatment and may eventually seek surgical management. The purpose of this study was to compare the clinical outcomes in patients who completed non-operative (non-op) therapy to those who failed non-operative therapy and proceeded to AC reconstruction.Methods:This is a level 3 study. Institutional Review Board approval was obtained prior to initiation of this study. 38 patients were initially treated non-op for acute grade III AC joint injuries with physical therapy. Demographic and surgical data along with pre- and post-treatment clinical outcomes scores including ASES, SF-12 PCS, QuickDASH, and SANE scores were collected a minimum of two years after initial presentation. Non-op failure occurred when a patient underwent AC reconstruction before final follow-up.Results:38 patients with a mean age of 38 years (range, 22-79 years) were included. 28/38 (74%) successfully completed non-op treatment whereas 10/38 (26%) failed after a median of 44 days (range, 6 days-17 months) from the initiation of physical therapy. Of the 10 patients who failed, 9 (90%) sought treatment >30 days after the injury. Two of these patients had a subsequent surgery before final follow-up and were therefore not included in outcomes analysis. Follow-up was available for the remaining 7/8 patients (87.5%) who failed non-op treatment and for 22/28 patients (78%) who were successfully treated non-op. Mean follow up was 3.3 years (range, 2.0-5.9). There were no significant differences in all outcomes scores between groups (p>0.05): Mean SF-12 PCS was 56.1 (range, 52.4-61.4) in those who successfully completed non-op treatment compared to 56.2 points (range, 53.1-58.0) in those who finally underwent surgery (p=0.680). Mean SANE score was 96 points (range, 65-100) in those who successfully completed non-op treatment compared to 95 points (range, 24-98) in those who finally underwent surgery (p=0.175). Mean ASES score was 95.5 points (range, 51-100) in patients with successful non-op treatment and 97.1 points (range, 91.6-100) in patients with eventual surgery (p=0.348). The mean QuickDASH score was 2.2 points in both groups with a range of 0-41 for those with successful non-op treatment and a range of 0-14 for those with eventual surgery (p=0.756). Patients who sought treatment >30 days after injury demonstrated decreased postoperative SANE scores (p = 0.002) and had 13.8 fold greater relative risk for failure of non-op treatment.Conclusion:Surgical decision making for patients with acute grade III AC joint injuries is evolving. According to our results, (1) a trial of non-op treatment is warranted as successful outcomes can be expected even in those that eventually opt for surgery, and (2) patients who present >30 days after their injury are much less likely to complete nonoperative treatment successfully.

All-Arthroscopic Suprapectoral versus Open Subpectoral Tenodesis of the Long Head of the Biceps Brachii

Objectives:Pathology of the long head of the biceps tendon is a recognized source of shoulder pain in adults that can be treated with tenotomy or tenodesis when non-operative measures are not effective. It is not clear whether arthroscopic or open biceps tenodesis has a clinical advantage. To date, we are not aware of any studies that directly compare clinical outcomes between an arthroscopic and an open technique for tenodesis of the long head of the biceps brachii. The purpose of this study was to determine whether a difference in outcomes and complications exists between matched cohorts after biceps tenodesis utilizing an open subpectoral versus an all-arthroscopic suprapectoral technique.Methods:A prospective database was reviewed for patients undergoing an all-arthroscopic suprapectoral or open subpectoral biceps tenodesis. Adult patients with a minimum 18-month follow-up were included. Patients undergoing a concomitant rotator cuff or labral repair were excluded. The groups were matched to age within 3 years, sex, and time to follow-up within 3 months. Pain improvement, development of a popeye deformity, muscle cramping, post-operative ASES scores, satisfaction scores, and complications were evaluated.Results:Forty-six patients (23 all-arthroscopic, 23 open) patients with an average age of 57.2 years (range, 45-70) were evaluated at a mean 28.7 months (range, 18-42) follow-up. No patients in either group developed a popeye deformity or complained of arm cramping. There was no significant difference in mean ASES scores between the open and all-arthroscopic groups (92.7 vs. 88.9, P = 0.42, Table 1). Similarly, there was no significant difference between patient satisfaction scores (8.9 vs. 9.1, P = 0.73). Eighteen patients (78.3%) in the arthroscopic cohort and sixteen patients (69.6%) in the open cohort fully returned to athletic activity (P = 0.50). There were no complications in the all-arthroscopic group. There were two complications in the open group (superficial incisional erythema, and brachial plexopathy) that resolved by final follow-up.Conclusion:Biceps tenodesis is a reliable treatment option for pathology of the long head of the biceps that may avoid arm cramping and a cosmetic “popeye” deformity that can occur following tenotomy. Open subpectoral and all-arthroscopic suprapectoral are two commonly used techniques to reattach the biceps tendon distal to the bicipital groove. In this study, patients undergoing an all-arthroscopic tenodesis experienced similar pain relief, shoulder function, and return to athletic activity as patients undergoing an open tenodesis. An open subpectoral technique may increase the risk of complications secondary to a larger incision and increased surgical dissection. Larger studies with longer follow-up would help delineate the long-term effects and potential differences between an all-arthroscopic suprapectoral and open subpectoral biceps tenodesis.

Resultados preliminares da osteossíntese com haste de Ender, por meio da técnica percutânea nas fraturas diafisárias do úmero nos adultos

ObjectiveTo demonstrate the clinical and functional results from treatment of humeral diaphysis fractures using Ender nails. MethodsEighteen patients who underwent osteosynthesis of humeral diaphysis fractures using Ender nails were evaluated. In addition to the clinical and radiographic evaluations, patients with a minimum of one year of follow‐up were assessed by means of the Constant, American Shoulder and Elbow Surgeons (Ases), Mayo Clinic and Simple Shoulder Value (SSV) functional scores, and in relation to the degree of satisfaction with the final result. The fixation technique used was by means of an anterograde percutaneous route. ResultsAll the patients achieved fracture consolidation, after a mean of 2.9 months (ranging from two to four months). The mean Constant score was 85.7 (ranging from 54 to 100) and the mean ASES score was 95.9 (ranging from 76 to 100). All the patients achieved the maximum score on the Mayo Clinic scale. ConclusionFixation of humeral diaphysis fractures using Ender nails by means of a percutaneous technique was shown to be a method with promising preliminary results.

Continuous Loop Double Endobutton Reconstruction for AC Joint Dislocation

Complete dislocation of the AC joint is a common clinical problem with an incidence of approximately 40,000 cases per year nationally. Despite the introduction of more anatomically based approaches, issues with construct slippage and failure remain a problem. This study presents the results of a procedure that was developed using a continuous loop double endobutton design anatomically placed using only a small (4.5mm) single drill hole in each bone and utilizing an open deltoid splitting approach. It was hypothesized that by combining a fixation construct that was strong, stiff and durable with a complete soft tissue repair in acute cases and an augmented repair in chronic cases the goal of consistent excellent outcomes could be achieved. Between 2003 and 2012, 30 patients (27 men, 3 women) were surgically treated for a Type 3 or greater AC joint dislocation with the described method (25 chronic and 5 acute). Mean age was 42.6 (range 25-66). Imbrication of the AC joint capsule was done in all cases and the fixation construct was augmented with a CA ligament transfer to the anterior edge of the clavicle in 26 cases and repair of the coracoclavicular ligament in 4 cases The distal clavicle was excised in 7 cases and left intact in 23 cases. 27 patients were available for follow-up at an average of 4.0 years (range 1-10.5). All patients underwent a complete interview, physical exam, and had bilateral radiographs taken. Final outcome scores were obtained using validated scoring methods. The construct remained stable in all cases, with no cases of gross failure and a mean CC interval difference of 1.1 mm (range -1.0 to 3.5). 91 % of all cases had a CC interval difference of 2 mm or less. The mean Constant score was 98 (range 94-100), the UCLA score was 33.7 (range 27-35) and the mean ASES score was 98 (range 88-100). Removal of the distal clavicle did not affect final results. There were no complications with regard to fixation failure, fractures, or infection. Uniformly excellent long-term results were obtained using this technique. A systematic approach to stabilizing the joint in two planes (horizontal and vertical) appears to be critical to successful results. By utilizing an open surgical approach, reconstruction of the torn and/or stretched AC joint capsule was possible. For vertical stability, a continuous loop device optimizes the outcome by eliminating the possibility of knot slippage or breakage and also allows for uniform loading of the suture material. Finally, it is essential to augment the construct with a biologic component either by augmenting with a graft or by meticulously repairing the torn CC ligaments. Using an open approach and keeping drill holes to a minimum in both size and number avoids complications that are common in arthroscopic techniques. The final outcome for both acute and chronic dislocations in this study is significantly superior to nonsurgical treatment. This technique can be recommended as the preferred treatment for patients with acute Type 3 and above AC joint dislocations.

Treatment of Acute Acromioclavicular Joint Injuries Using AO Hook Locking Plate

BACKGROUND: To evaluate clinical and radiological outcome using AO hook locking plate in acute acromioclavicular joint injuries.METHODS: This study was based on patients with Rockwood type 3 or 5 acromioclavicular joint injuries who received surgery with AO hook locking plate from June 2008 until June 2009. Among the 22 patients, 19 of them were male and 3 were female, the mean age was 44.4 +/- 15.57 years (20-72 years) and follow-up period was 15.5 +/- 3.90 months (12-23 months). Preoperatively, postoperatively, and at the final follow-up after the plate removal, both coracoclavicular distances were measured from the anteroposterior radiograph. Also, the Shoulder Rating Scale of the University of California at Los Angeles scores (UCLA scores), the American Shoulder and Elbow Surgeons scores (ASES scores), Constant scores, and the Korean Shoulder Society scores (KSS scores) were measured at the final follow-up to evaluate the function of the shoulder joint.RESULTS: At the time of injury, the mean coracoclavicular distance of the injured side was 17.69 +/- 4.23 mm (9.57-27.82 mm) and the unaffected side was 7.55 +/- 2.20 mm (3.24-13.05 mm). The mean coracoclavicular distance measured postoperatively and at the final follow-up was 6.87 +/- 2.34 mm (4.07-14.13 mm) and 8.47 +/- 2.96 mm (4.37-17.48 mm), respectively. The mean UCLA, ASES, Constant, and KSS scores measured in the final follow-up were 33.5 +/- 1.30 (31-35), 90.8 +/- 8.36 (72-100), 78.6 +/- 8.80 (62-100), and 94.4 +/- 5.08 (84-100) each.CONCLUSIONS: From this short-term research, the surgical treatment using AO hook locking plates in acute acromioclavicular joint injuries is clinically and radiographically satisfying and considered as a useful treatment method.