Mean Internal Rotation Research Articles

Radiographic Assessment of the Safe Zone for Medial Oblique Opening Wedge High Tibial Osteotomy

To compare different cephalocaudal angles of the X-ray beam in measuring internal rotation of the proximal tibia that best demonstrates the safe zone. 10 pairs of embalmed, disarticulated knee joints from 10 cadavers were used. Soft tissues around the proximal tibia and the proximal tibiofibular joint (PTFJ) were dissected to reveal the articular cartilage. A narrow area between the end of the articular cartilage of the posterolateral proximal tibia and of the PTFJ was identified as the safe zone with a U-shape metal used as a radiographic marker. Translation of the proximal tibia was controlled during internal rotation of the proximal tibia. Internal rotation of the proximal tibia that best demonstrated the safe zone (the U-shape metal at its most outermost point) was measured at 0º, 5º, 10º, 15º, 20º, and 25º cephalocaudal angles of the X-ray beam. The mean internal rotation of the proximal tibia that best demonstrated the safe zone at 0º, 5º, 10º, 15º, 20º, and 25º cephalocaudal angle of the X-ray beam were 50º, 45º, 37º, 32º, 23º, and 19º, respectively. The safe zone was best demonstrated with 50º and 45º internal rotation of the proximal tibia at 0º and 5º cephalocaudal angles of the X-ray beam, respectively.

Early micromovement of the Articular Surface Replacement (ASR) femoral component

Radiostereometric analysis (RSA) can detect early micromovement in unstable implant designs which are likely subsequently to have a high failure rate. In 2010, the Articular Surface Replacement (ASR) was withdrawn because of a high failure rate. In 19 ASR femoral components, the mean micromovement over the first two years after implantation was 0.107 mm (sd 0.513) laterally, 0.055 mm (sd 0.204) distally and 0.150 mm (sd 0.413) anteriorly. The mean backward tilt around the x-axis was -0.08° (sd 1.088), mean internal rotation was 0.165° (sd 0.924) and mean varus tilt 0.238° (sd 0.420). The baseline to two-year varus tilt was statistically significant from zero movement, but there was no significant movement from one year onwards. We conclude that the ASR femoral component achieves initial stability and that early migration is not the mode of failure for this resurfacing arthroplasty.

Evaluation of intraoperative anterior cruciate ligament laxity using a navigation system in the anatomical single bundle reconstruction

PurposeThe anatomical anterior cruciate ligament (ACL) reconstruction attempts to, by reproducing the natural orientation of its fibres, achieve a better rotational stability of the knee. The aim of this paper is to quantify the anteroposterior and rotational laxity of the knee before and after an anatomic ligamentoplasty using the Orthopilot® navigation system as a supporting tool. Material and methodWe describe the distinctive steps of Orthopilot® navigation as well as conducting a retrospective cross-sectional study on a cohort of 20 patients operated in our hospital for chronic primary ACL rupture from January 2010 to May 2011. The precise location of the tunnels was defined with the help of the navigator and the intra-articular landmarks and stability tests were performed in both the sagittal and axial planes. ResultsIn our technique for anatomical ACL reconstruction placed the tibial tunnel at a mean distance of 16.8±4.92mm from the posterior cruciate ligament in a position that represented 44.1±4.35% of the total width of the tibial plateau. The average distance from the centre of the femoral tunnel to the posterior cortex of the lateral condyle was 7.89±2.78mm. Intra-operatively and before ACL reconstruction, the mean (±SD) anteroposterior movement, internal rotation and external rotation of the tibia at 30° position were 15.5mm (±5.11), 19° (±3.62) and 19.65° (±3.26), respectively. After reconstruction these values decreased to 5.6mm (±1.72°), 12.17° (±3.76) and 16.9° (±4.42), respectively. ConclusionsThe use of navigation systems supporting the surgery allows the systematic positioning of bone tunnels and standardises the procedures for the desired reconstruction. ACL reconstruction using the technique described, improves the anteroposterior and rotational stability compared to preoperative status, to a stability state that could be considered physiological according to current scientific knowledge.

Effects and predictors of shoulder muscle massage for patients with posterior shoulder tightness

BackgroundClinical approaches like mobilization, stretching, and/or massage may decrease shoulder tightness and improve symptoms in subjects with stiff shoulders. We investigated the effect and predictors of effectiveness of massage in the treatment of patients with posterior shoulder tightness.MethodsA randomized controlled trial was conducted in a hospital-based outpatient practice (orthopedic and rehabilitation). Forty-three women and 17 men (mean age = 54 years, range 43-73 years) with posterior shoulder tightness participated and were randomized into massage and control groups (n = 30 per group). A physical therapist provided the massage on the posterior deltoid, infraspinatus, and teres minor of the involved shoulder for 18 minutes [about 6 minutes for each muscle] two times a week for 4 weeks. For the control group, one therapist applied light hand touch on the muscles 10 minutes two times a week for 4 weeks. Glenohumeral internal rotation ROM, functional status, and muscle tightness were the main outcomes. Additionally, the potential factors on the effectiveness of massage were analyzed by multivariate logistic regression. For this analysis, patients with functional score improvement at least 20% after massage were considered responsive, and the others were considered nonresponsive.ResultsFifty-two patients completed the study (29 for the massage and 23 for the control). The overall mean internal rotation ROM increased significantly in the massage group compared to the control (54.9° v.s. 34.9°; P ≤ 0.001). There were 21 patients in the responsive group and 8 in the nonresponsive group. Among the factors, duration of symptoms, functional score, and posterior deltoid tightness were significant predictors of effectiveness of massage.ConclusionsMassage was an effective treatment for patients with posterior shoulder tightness, but was less effective in patients with longer duration of symptoms, higher functional limitation, and less posterior deltoid tightness.Trial registrationThis clinical trial is registered at Trial Registration "Trial registration: Clinicaltrials.gov NCT01022827".

Evaluación mediante navegación intraoperatoria de la laxitud del ligamento cruzado anterior en su reconstrucción anatómica monofascicular

PurposeThe anatomical anterior cruciate ligament (ACL) reconstruction attempts to, by reproducing the natural orientation of its fibres, achieve a better rotational stability of the knee. The aim of this paper is to quantify the anteroposterior and rotational laxity of the knee before and after an anatomic ligamentoplasty using the Orthopilot® navigation system as a supporting tool. Matherial and methodWe describe the distinctive steps of Orthopilot® navigation as well as conducting a retrospective cross-sectional study on a cohort of 20 patients operated in our hospital for chronic primary ACL rupture from january 2010 to may 2011. The precise location of the tunnels was defined with the help of the navigator and the intra-articular landmarks and stability tests were performed in both the sagittal and axial planes. ResultsIn our technique for anatomical ACL reconstruction placed the tibial tunnel at a mean distance of 16.8±4.92mm from the posterior cruciate ligament in a position that represented 44.1%±4.35 of the total width of the tibial plateau. The average distance from the centre of the femoral tunnel to the posterior cortex of the lateral condyle was 7.89±2.78mm. Intra-operatively and before ACL reconstruction, the mean (±SD) anteroposterior movement, internal rotation and external rotation of the tibia at 30° position were 15.5mm (±5.11), 19° (±3.62) and 19.65° (±3.26), respectively. After reconstruction these values decreased to 5.6mm (±1.72°), 12.17° (±3.76) and 16.9° (±4.42), respectively. ConclusionsThe use of navigation systems supporting the surgery allows the systematic positioning of bone tunnels and standardises the procedures for the desired reconstruction. ACL reconstruction using the technique described, improves the anteroposterior and rotational stability compared to preoperative status, to a stability state that could be considered physiological according to current scientific knowledge.

Arthroscopic stabilization for Neer type 2 fracture of the distal clavicle fracture

The distal clavicle fractures are divided into three types according to Neer's classification. Types 1 and 3 fractures are treated with a sling to immobilize the upper extremity. However, the treatment of type 2 fractures is controversial. We paid attention to the anatomic basis of type 2 fractures that the disruptions of the conoid ligament lead to the distraction between the two bony fragments. In this study, we describe the arthroscopic procedure to reconstruct the disrupted ligament and stabilize the fracture as a minimally invasive method. The subjects were seven patients with the distal clavicle fractures. According to Neer's or Rockwood's classification on plain radiographs, all seven patients were evaluated as type 2 or 2B, respectively. Our surgical procedure was performed with the patient in the beach chair position. We have used the artificial ligament with an EndoButton (Smith & Nephew Endoscopy, Andover, MA) as the substitute ligament to reconstruct the disrupted conoid ligament. The mean duration of postoperative follow-up was 2years and 5months. The bony union was achieved in all patients at a final follow-up. When concerning the range of motion at final examinations, mean forward flexion was 171°, mean abduction was 165°, mean internal rotation was Th11, and mean horizontal adduction was 132°. It is possible to treat the distal clavicle fractures by a minimally invasive arthroscopic procedure without opening the fracture site of clavicle.

Computer-Assisted Modeling of Osseous Impingement and Resection in Femoroacetabular Impingement

The purpose of this study was to evaluate the utility of computer-assisted 3-dimensional modeling in diagnosing and treating symptomatic hip impingement. Eight patients with symptomatic, focal cam and/or pincer impingement lesions underwent high-resolution computed tomography scans and computer-assisted, 3-dimensional modeling of the involved hip. Cam location, alpha angle, neck-shaft angle, femoral version, and acetabular version at the 12-o'clock through 3-o'clock positions were measured. The model was subsequently dynamized to define the preoperative range of motion and location of impingement with hip flexion, internal rotation, and internal rotation at 90° of hip flexion. Virtual cam and pincer osteoplasty was performed to establish normal head-neck offset and head sphericity and to eliminate focal rim impingement lesions. Range of motion and location of impingement were reassessed after resection in the defined area of impingement. The cam lesion was located between the 12-o'clock and 4-o'clock positions in all cases. The mean alpha angle was 66.4° (range, 53° to 80°). Mean femoral version was 14.6° (range, 5° to 23°). Mean preoperative hip flexion was 109.7° (range, 87.5° to 125.5°), and mean internal rotation at 90° of hip flexion was 16.2° (range, 1.7° to 25.5°). The location of impingement was unique in each case and not predictable based on radiographic measures alone. Virtual osteoplasty in the defined regions of impingement resulted in significant improvements in both hip flexion and internal rotation (P < .05). Computed tomography-based computer modeling can localize regions of anticipated mechanical impingement in symptomatic patients with hip pain. Computer-assisted navigation may be a valuable surgical tool to more accurately and reliably eliminate offending impingement lesions. Level IV, diagnostic study.

Surgical Treatment of Femoroacetabular Impingement Improves Hip Kinematics

Background Femoroacetabular impingement (FAI) is now recognized as the most common cause of early osteoarthritis in the nondysplastic hip. While the surgical treatment of FAI has demonstrated favorable clinical outcomes, the ability of an osteoplasty to reliably improve hip kinematics and range of motion remains unknown. Purpose This study used computer-assisted 3-dimensional (3D) analysis to assess differences in hip range of motion before and after the arthroscopic surgical treatment of symptomatic FAI. Study Design Case series; Level of evidence, 4. Methods Ten patients with symptomatic, focal cam and/or pincer impingement lesions underwent high-resolution computed tomography scans and computer-assisted 3D modeling of the involved hip before and after corrective arthroscopic surgery by the senior author. Cam location, alpha angle, neck-shaft angle, femoral version, and acetabular version at 12-o'clock through 3-o'clock positions were measured. The model was subsequently dynamized to define the preoperative and postoperative range of motion and location of impingement with hip flexion, internal rotation, and internal rotation at 90° of hip flexion. Statistical analysis of preoperative and postoperative hip flexion and internal rotation at 90° of hip flexion was performed using paired t tests with P < .05 defined as significant. Results The cam lesion was located between 12 o'clock and 5 o'clock in all cases. Mean preoperative alpha angle was 59.8° (range, 36°-76°). Mean femoral version was 12.5° (range, −15° to 32°). Mean preoperative hip flexion was 107.40° ± 11.6°, and mean internal rotation at 90° of hip flexion was 19.10° ± 13.0°. The location of impingement was unique in each case and not predictable based on simple radiographic measures (ie, alpha angle) alone. Corrective femoral and rim osteoplasty resulted in significant improvements in both hip flexion (3.8°; P = .002) and internal rotation (9.3°; P = .0002). Mean postoperative alpha angle was 36.4° (range, 22°-46°). Conclusion Focal cam and/or rim osteoplasty can reliably improve hip kinematics and range of motion in patients with symptomatic FAI, particularly the limitation of internal rotation in a flexed position. Computed tomography–based computer modeling can localize regions of anticipated mechanical impingement in symptomatic patients. A complete osteoplasty in these defined regions, through an arthroscopic or open approach, predictably improves range of motion and may help to eliminate the recurrent mechanical collision and secondary chondral injury associated with FAI.

Can femoroacetabular impingement and hip dysplasia be distinguished by clinical presentation and patient history?

Hip dysplasia and femoroacetabular impingement may both lead to disability and hip osteoarthritis. The purpose of the current study was to compare the two entities in order to define differences in their clinical presentation. The clinical presentation and WOMAC items, subscales and overall sum score were compared between 37 patients with femoroacetabular impingement and 37 patients with hip dysplasia. The average duration of symptoms was 33.3 ± 31.6 months in patients with femoroacetabular impingement and 34.5 ± 39.0 months in patients with dysplasia (p = 0.885). The anterosuperior impingement test was positive in all patients with femoroacetabular impingement and in 92% of hip dysplasia patients (p = 0.061). Mean internal rotation and abduction was significantly less in patients with femoroacetabular impingement (p = 0.001 and 0.007). The WOMAC subscales for pain, stiffness, and functionality as well as the overall sum score were not significantly different between patients with femoroacetabular impingement and patients with hip dysplasia. The qualitative analysis of WOMAC items revealed that symptoms related to sitting were significantly more often rated to be present in femoroacetabular impingement than in hip dysplasia patients. In the quantitative analysis, only the item 'getting in or out of a car' was rated significantly more severe in patients with femoroacetabular impingement. In addition to obtaining a detailed history and examination, radiographic studies are needed for differentiation of the two entities and for the decision on treatment strategy.

Treatment of Slipped Capital Femoral Epiphysis with a Modified Dunn Procedure

Surgical procedures with use of traditional techniques to reposition the proximal femoral epiphysis in the treatment of slipped capital femoral epiphysis are associated with a high rate of femoral head osteonecrosis. Therefore, most surgeons advocate in situ fixation of the slipped epiphysis with acceptance of any persistent deformity in the proximal part of the femur. This residual deformity can lead to secondary osteoarthritis resulting from femoroacetabular cam impingement. We retrospectively assessed the cases of twenty-three patients with slipped capital femoral epiphysis after surgical correction with a modified Dunn procedure, an approach that included surgical hip dislocation. The study reviewed the clinical status and radiographs made at the time of surgery, as well as the intraoperative findings. At a minimum follow-up of twenty-four months after surgery, the motion of the treated hip was compared with the motion of the contralateral hip, and the radiographic findings related to the anatomy of the femoral head-neck junction, as well as signs of early osteoarthritis or osteonecrosis, were evaluated. Twenty-one patients had excellent clinical and radiographic outcomes with respect to hip function and radiographic parameters. Two patients who developed severe osteoarthritis and osteonecrosis had a poor outcome. The mean slip angle of the femoral head of 47.6° preoperatively was corrected to a normal value of 4.6° (p < 0.0001). The mean flexion and internal rotation postoperatively were 107.3° and 37.8°, respectively. The mean range of motion of the treated hips was not significantly different (p > 0.05) from that of the normal, contralateral hips. Of the eight hips that were considered unstable in the intraoperative clinical assessment, six had been considered stable preoperatively. The treatment of slipped capital femoral epiphysis with the modified Dunn procedure allows the restoration of more normal proximal femoral anatomy by complete correction of the slip angle, such that probability of secondary osteoarthritis and femoroacetabular cam impingement may be minimized. The complication rate from this procedure in our series was low, even in the treatment of unstable slipped capital femoral epiphysis, compared with alternative procedures described in the literature for fixation of slipped capital femoral epiphysis.

Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness?

Conservative rehabilitation after arthroscopic rotator cuff repair does not result in long-term stiffness and improves rates of tendon healing. We retrospectively evaluated 43 patients with full-thickness rotator cuff tears who underwent a standardized, conservative protocol of full-time sling immobilization without formal therapy for 6 weeks after arthroscopic repair. At 6 to 8 weeks of follow-up, we categorized patients as "stiff" if they demonstrated forward elevation of less than 100° and external rotation of less than 30° passively; all others were designated "nonstiff." Active range of motion in forward elevation, external rotation, and internal rotation was assessed at 3 months, 6 months, and 1 year. American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores were assessed at 1 year. Follow-up magnetic resonance imaging (MRI) was obtained in all patients to assess tendon healing. Ten patients (23%) were considered stiff after rotator cuff surgery. At 1 year, there was no difference in mean forward elevation (166° vs 161°, P = .2), external rotation (62° vs. 58.4°, P = .5), or internal rotation (T7.4 vs T8.2, P = .07) between the stiff and nonstiff groups, respectively. There were no differences in final ASES (83 vs 79, P = .57) and Constant-Murley scores (77 vs. 74, P = .5). Repeat MRI suggested a trend toward a lower retear rate among the stiff patients (70% intact in stiff group vs 36% in nonstiff group, P = .079). Two clinically significant cuff retears occurred in the nonstiff cohort. Concerns for recalcitrant stiffness have led some to favor early postoperative therapy. We found that early restriction of motion did not lead to long-term stiffness after arthroscopic rotator cuff repair, even in patients who were clinically stiff in the early postoperative period. Sling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in increased long-term stiffness and may improve the rate of tendon healing.

Randomised controlled trial comparing early migration of two collarless polished cemented stems using radiostereometric analysis

This was a safety study where the hypothesis was that the newer-design CPCS femoral stem would demonstrate similar early clinical results and micromovement to the well-established Exeter stem. Both are collarless, tapered, polished cemented stems, the only difference being a slight lateral to medial taper with the CPCS stem. A total of 34 patients were enrolled in a single-blinded randomised controlled trial in which 17 patients received a dedicated radiostereometric CPCS stem and 17 a radiostereometric Exeter stem. No difference was found in any of the outcome measures pre-operatively or post-operatively between groups. At two years, the mean subsidence for the CPCS stem was nearly half that seen for the Exeter stem (0.77 mm (-0.943 to 1.77) and 1.25 mm (0.719 to 1.625), respectively; p = 0.032). In contrast, the mean internal rotation of the CPCS stem was approximately twice that of the Exeter (1.61 degrees (-1.07 degrees to 4.33 degrees ) and 0.59 degrees (0.97 degrees to 1.64 degrees ), respectively; p = 0.048). Other migration patterns were not significantly different between the stems. The subtle differences in designs may explain the different patterns of migration. Comparable migration with the Exeter stem suggests that the CPCS design will perform well in the long term.

Arthroscopic capsular release for refractory shoulder stiffness: A critical analysis of effectiveness in specific etiologies

The purpose of this study is to report and compare the outcome of arthroscopic capsular release in patients with shoulder stiffness with post-traumatic, postsurgical, and idiopathic etiologies. We hypothesize that patients with idiopathic or post-traumatic stiffness have better outcomes after arthroscopic capsular release than those with shoulder stiffness with a postsurgical etiology. A retrospective review of 115 patients who underwent arthroscopic capsular release for refractory shoulder stiffness was performed. There were 60 men and 55 women with a mean age of 49 years (range, 27 to 81 years). The patients were divided into 3 groups according to the etiology of stiffness: post-traumatic (26 patients), postsurgical (48 patients), and idiopathic (41 patients). Arthroscopic capsular release was performed in all patients after a mean of 9 months of physical therapy (range, 6 to 13 months). At a mean follow-up of 46 months (range, 25 to 89 months), the overall subjective shoulder value in all groups improved from 29% to 73% and the age- and gender-adjusted Constant score improved from 35% to 86%. The mean pain score decreased from 7.5 to 1, and mean active forward flexion, external rotation, and internal rotation increased from 97 degrees , 14 degrees , and the L5 vertebral level, respectively, to 135 degrees , 38 degrees , and the T11 vertebral level, respectively (P < .0001). There was no significant difference between the outcomes of idiopathic and post-traumatic stiffness (P = .7). However, the Constant score and subjective shoulder value were significantly lower in the postsurgical group compared with the idiopathic and post-traumatic groups (P = .0001 and P = .006, respectively). Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness. Patients with idiopathic and post-traumatic shoulder stiffness have better outcomes than patients with postsurgical stiffness.

Three-Dimensional Shoulder Kinematics to Complete Activities of Daily Living

To describe the contributions of glenohumeral and scapulothoracic joints in performing combing hair, feeding, reaching overhead, washing the back, and washing the contralateral axilla. A three-dimensional electromagnetic motion capture system was used to collect humerus, scapula, and trunk kinematic data during activities of daily living completion. Descriptive statistics were calculated for the primary humerothoracic motion. Forward multiple regression analyses explained the variation accounted for by glenohumeral and scapulothoracic motions. The mean internal rotation to accomplish back washing was 85 (standard deviation 24) degrees glenohumeral internal rotation contributed. The mean humerothoracic elevation ranged between 46 (standard deviation 12) degrees for washing the contralateral axilla and 119 (standard deviation 10) degrees for hair combing. Glenohumeral abduction, scapular anterior tipping, and scapular upward rotation contributed to completing feeding, hair combing, reaching overhead, and washing the contralateral axilla. Glenohumeral flexion contributed to completing feeding, reaching overhead, and washing the contralateral axilla. Scapular internal rotation contributed to completing feeding. Glenohumeral abduction and scapulothoracic upward rotation were necessary to accomplish feeding, combing hair, reaching overhead, and washing the contralateral axilla. Glenohumeral internal rotation was necessary to accomplish back washing. Interventions addressing glenohumeral and scapulothoracic motions in patients who are having difficulty in completing activities of daily livings may prove beneficial.

Tratamento artroscópico do impacto femoroacetabular

Objective: The purpose of this study is to evaluate the short- term follow-up results of arthroscopic treatment of femoro- acetabular impingement. Our hypothesis is that arthroscopic treatment results are favorable. Methods: Between August 2003 and August 2007, 28 hips had femoroacetabular im- pingement treated by hip arthroscopy. The mean age was 34 years, with mean follow-up period of 27 months. Clini- cal results were graded with the modified Harris hip score, which was measured pre- and postoperatively. Patients had also their internal rotation analyzed. These parameters were calculated by using Wilcoxon's t test for analysis of nonpara- metric paired samples performed. Results: The mean preop- erative Harris Hip Score was 54.2, improving to 94.8 post- operatively (p<0,001). The mean increase was 37.5 points. We had 4 good results (15%) and 24 excellent results (85%). Preoperatively, the patients had a mean internal rotation of 17°, and, postoperatively, 36°. The average internal rotation increase was 19° (p<0,001).Conclusions: The arthroscopic treatment of femoroacetabular impingement presents satis- factory results.

ARTHROSCOPIC TREATMENT OF FEMOROACETABULAR IMPINGEMENT

Objective: The purpose of this study is to evaluate the short-term follow-up results of arthroscopic treatment of femoroacetabular impingement. Our hypothesis is that arthroscopic treatment results are favorable. Methods: Between August 2003 and August 2007, 28 hips had femoroacetabular impingement treated by hip arthroscopy. The mean age was 34 years, with mean follow-up period of 27 months. Clinical results were graded with the modified Harris hip score, which was measured pre- and postoperatively. Patients had also their internal rotation analyzed. These parameters were calculated by using Wilcoxon's t test for analysis of nonparametric paired samples performed. Results: The mean preoperative Harris Hip Score was 54.2, improving to 94.8 postoperatively (p<0,001). The mean increase was 37.5 points. We had 4 good results (15%) and 24 excellent results (85%). Preoperatively, the patients had a mean internal rotation of 17°, and, postoperatively, 36°. The average internal rotation increase was 19° (p<0,001). Conclusions: The arthroscopic treatment of femoroacetabular impingement presents satisfactory results.

Traumatic Anterosuperior Rotator Cuff Tears: The Outcome of Open Surgical Repair

Anterosuperior rotator cuff tears involving the subscapularis and supraspinatus tendons are less common than posterosuperior tears and are rarely discussed in the literature. The purpose of this study was to identify the unique features of this injury and to assess the outcome of operative treatment. Thirty consecutive patients, with a mean age of fifty-seven years (range, forty-three to seventy-three years), had an open repair of a traumatic anterosuperior rotator cuff tear. Twenty-four patients (80%) were male. Sixteen patients (53%) had involvement of the dominant shoulder, twenty-three (77%) had a biceps tendon disorder, and sixteen (53%) had a positive lift-off maneuver prior to surgery. Surgical approaches included an isolated superior deltoid-splitting approach in twenty patients, an isolated deltopectoral approach in five patients, and a combined approach in five patients. Open repair was performed at a mean of 4.5 months after the injury or the onset of symptoms. The final outcomes were determined with a physical examination and patient self-assessed outcome tools. At a mean follow-up of fifty-six months, twenty-one of the thirty patients were satisfied with their symptoms, and twenty-nine would have the surgery again. The mean pain score on the visual analog scale improved from 6.2 to 1.2 (p < 0.001). The mean score on the Disabilities of the Arm, Shoulder and Hand questionnaire improved from 41.7 to 12.2 (p < 0.001). The mean percentage of functions that patients were able to perform on the Simple Shoulder Test improved from 36.4% to 82.8% (p < 0.001). The mean age and sex-adjusted Constant score was 93.4 postoperatively. The mean elevation, external rotation, and internal rotation of the involved shoulders were 97%, 109%, and 97%, respectively, of those of the contralateral side. The mean strength of elevation, external rotation, and internal rotation were 85%, 93%, and 101%, respectively, of those of the contralateral side. Infraspinatus involvement (p = 0.04), the extent of the supraspinatus tear (p = 0.03), and a Workers' Compensation claim (p = 0.03) were associated with worse outcomes and decreased satisfaction. Patients with a traumatic anterosuperior rotator cuff tear present with internal rotation weakness, and they usually have a biceps tendon disorder. While larger tears involving greater portions of the supraspinatus and extending into the infraspinatus are associated with poorer outcomes, early recognition of this injury and open repair can reliably restore shoulder function to near normal levels.

The results of two-stage re-implantation for infected shoulder replacement

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation. We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42 degrees (0 degrees to 140 degrees ) to 89 degrees (0 degrees to 165 degrees ), mean external rotation from 30 degrees (0 degrees to 90 degrees ) to 43 degrees (0 degrees to 90 degrees ), and mean internal rotation from the sacrum to L5. There were 14 complications. Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate.

Three-dimensional computed tomography analysis and anteversion study after periacetabular osteotomy of pelvis in children

Three-dimensional computed tomography (CT) is the method of choice in understanding the morphological changes after periacetabular osteotomy in children. We studied different parameters and compared aspects of operated hip (OH) with non-operated hip (NOH) to define the maneuver that promotes normalization of the hip during repositioning of the acetabulum. A total of 22 patients with 25 OHs underwent CT control scans an average of 4 years after surgery. The patients, with a mean age of 6.8 years, had either Legg-Calvé-Perthes disease (12 cases) or dysplasia (10 cases).The measurements included the anterior and posterior coverage angles of the hip and version of the acetabulum on axial CT views. The 3D reconstructed images measured the inclination of the antero- and postero-lateral lips, the external rotation and the anterior inclination of the acetabulum. The mean anterior coverage angle was 27 degrees for OHs, 31 degrees for NOHs, and 12 degrees versus 10.3 degrees for the posterior coverage angle. Acetabular anteversion was 2 degrees for OHs (6.3 degrees in the dysplastic OHs) and 6 degrees for NOHs. The mean angle of inclination of the antero-lateral lip was 37 degrees for OHs, 47 degrees for NOHs, and the postero-lateral lip inclination was 56 degrees for OHs and 67 degrees for NOHs. Inferior 3D views showed a mean internal acetabular rotation of 1.5 degrees (4.8 degrees in the dysplastic OH), 3 degrees for NOH. The anterior acetabular inclination angle measured with lateral 3D views was 6 degrees for OHs, 11 degrees for NOHs. Our analysis demonstrated a mean anteversion of the acetabulum despite normalization of the anterior coverage of the hip, particularly in the dysplastic group, in which the osteotomized fragments had anteversion superior to NOH. The unexpected external rotation used to improve anterior coverage of a coax magna in Legg-Calvé-Perthes disease was responsible for the retroversion and the decrease of the posterior coverage.

Fraturas em duas e três partes do úmero proximal tratadas com sutura não absorvível

OBJETIVO: Avaliar os resultados clínicos e radiográficos dos pacientes com fraturas em duas e três partes da extremidade proximal do úmero tratados por sutura não absorvível, com incorporação do manguito rotador, o que permite aumentar a estabilidade da fixação, principalmente em pacientes com pobre qualidade óssea. MÉTODOS: Dezenove pacientes foram operados, sendo 15 do sexo feminino e quatro do masculino, com média de idade de 57,4 anos (23-79 anos) e seguimento médio de 53,4 meses (sete a 144 meses). De acordo com a classificação de Neer, havia 10 fraturas em três partes (colo cirúrgico e tubérculo maior) e nove fraturas em duas partes (duas do tubérculo maior e sete do colo cirúrgico). Todos foram operados na posição " cadeira de praia" , com anestesia endotraqueal e bloqueio do plexo braquial. O acesso deltopeitoral foi utilizado para fraturas em duas partes do colo cirúrgico e fraturas em três partes. Para fraturas em duas partes do tubérculo maior, foi utilizado acesso transacromial. As fraturas foram reduzidas e fixadas com sutura não absorvível nº 5. O ângulo cervicodiafisário foi medido para avaliação da consolidação viciosa. RESULTADOS: Verificou-se consolidação óssea em 95% dos pacientes. A média da elevação anterior nos pacientes com fratura em duas partes foi de 163,3° (90°-180°); a rotação externa média, de 56° (30° a 90°); e a rotação interna média, de T10 (S1-T5). Nos pacientes com fratura em três partes, a média de elevação anterior foi de 163° (100°-180°); a rotação externa média, de 52,5° (5°-70°) e a rotação interna média, de T10 (L4-T7). A força de abdução foi igual à do lado contralateral em 12 pacientes e menor em sete. O tempo necessário para o paciente retornar às atividades anteriores foi, em média, de 5,19 meses (dois a 12 meses). Na avaliação radiológica, o ângulo cervicodiafisário médio foi de 141° (110°-170°) nas fraturas em duas partes e de 150° (106°-210°) nas fraturas em três partes, sendo verificada consolidação em valgo em nove pacientes (59%) e, em varo, em dois pacientes. De acordo com o escore da UCLA, verificaram-se 88,8% de bons e excelentes resultados e 11,2% de maus resultados, para ambos os tipos de fratura. Os últimos, representados por um caso de pseudartrose e outro, por uma capsulite adesiva no pós-operatório. CONCLUSÃO: As fraturas em duas e três partes do úmero proximal podem ser satisfatoriamente tratadas com sutura não absorvível com incorporação do manguito rotador, particularmente nos idosos. Complicações relacionadas aos metais estão afastadas. Pacientes com fraturas do tubérculo maior tratados com suturas podem ter resultados similares aos daqueles com fraturas do colo cirúrgico. Embora o objetivo da cirurgia seja a reconstrução anatômica, alguma deformidade residual não impede resultado satisfatório. O método é pouco invasivo, permite estabilidade razoável dos fragmentos, com altos índices de consolidação óssea e satisfação do paciente. A cooperação do paciente é crucial para o sucesso terapêutico.