Impaired Shoulder Function Research Articles

Quilting following mastectomy reduces seroma, associated complications and health care consumption without impairing patient comfort.

BackgroundAn important complication following mastectomy is seroma formation. Quilting, in which skin flaps are sutured to the underlying muscle, is reported to reduce seroma incidence, but might induce pain and impair shoulder function. Main objective is to compare quilting with conventional wound closure, regarding seroma incidence, health care consumption, and patient discomfort.MethodsIn a combined prospective and retrospective study, 254 patients undergoing mastectomy and/or axillary lymph node dissection (ALND) were included. Patients received quilting sutures or conventional closure. Primary outcome was clinical significant seroma (CSS). In prospectively included patients shoulder function and analgesic use was observed.ResultsCSS incidence was 12.9% in the quilted versus 62.3% in the nonquilted cohort (p < 0.001). Surgical site infections were reported significantly less in the quilted cohort. Duration of hospital stay was shorter and outpatient clinic visits were less in the quilted cohort. Surgical procedure required 10 additional minutes for quilting. No significant differences were observed in postoperative shoulder function and analgesic use.ConclusionQuilting following mastectomy reduces CSS incidence. Quilting requires 10 additional minutes during surgery. It facilitates day treatment and results in less additional outpatient clinic visits culminating in reduced health care consumption. Shoulder function and pain are not affected by quilting.

Surgical management of winged scapula/shoulder disability in adults who failed conservative treatments.

Background: Scapular winging, muscle weakness, chronic discomfort, and overall impairment of shoulder function are commonly caused by injuries to and/or compression of the upper brachial plexus, long thoracic, and accessory nerves. These injuries can have significant social and financial impacts on patients.Methods: Twenty-one adults who sustained shoulder injuries (a bilateral injury in two patients and a total of 23 shoulder surgeries) presented with winged scapulas, limited shoulder range of motion, and severe shoulder pain.Results: Patients underwent unilateral decompression, neurolysis of the upper brachial plexus/long thoracic nerve (LTN), and partial resection of the scalene muscle. The mean shoulder abduction/flexion improved significantly, and 15 of 21 (71%) patients regained full range of motion (180°) postoperatively. In addition, the winged scapula appearance improved significantly in 20 of 21 patients (96%) postoperatively.Conclusion: All except one of 21 patients with scapular winging, muscle weakness, chronic discomfort, and overall impairment of shoulder function improved following unilateral decompression, neurolysis of the upper brachial plexus/LTN, and partial resection of the scalene muscle.

Harvest, Transport, and Storage of Fresh Humeral Head Osteochondral Allograft: Step-by-Step Protocol

Articular cartilage defects are not common in the glenohumeral joint and are mostly found in patients after shoulder trauma, in patients with recurrent instability, or in patients who underwent previous surgical treatment. Articular cartilage defects lead to pain and loss of motion, consequently causing shoulder function impairment and reducing quality of life. In young patients, the use of osteochondral allografts for the treatment of humeral head defects may avoid well-known complications of shoulder arthroplasty. The goal of this Technical Note is to describe a step-by-step protocol for the harvesting, transport, and preservation of fresh humeral head osteochondral tissue for use in allograft transplantation.

A 19-Year Experience With Clavicular Defects: An Algorithm for Flap Selection and Surgical Outcomes.

The clavicle contributes to the stability and functional integrity of the shoulder. Clavicle bone defects are uncommon, and the strategy for their management is variable. Six patients presented with clavicle bone defects. The causes were as follows: traumatic defects (2 patients), electric injury (1 patient), osteoradionecrosis (2 patients), and nonunion (1 patient). One patient had upper limb palsy for 40 years, and another had posttraumatic shoulder function impairment. A pedicled pectoralis major myocutaneous flap was used for the patient with a dysfunctional limb, and 5 bone flaps (3 free fibular flaps, 1 free iliac flap, and 1 pedicled rib flap) were used for reconstruction in the other patients. All flaps (2 pedicled flaps and 4 free flaps) were successfully used for wound repair; the pedicled rib flap demonstrated partial marginal necrosis, and the free fibular flap required reexploration for venous kinking. Five functionally impaired upper limbs showed functional improvements postoperatively. For functionless composite clavicles and soft tissue defects, a soft tissue flap will be required for wound repair. A bone flap, especially a fibular flap, is required for the upper limb to show functional recovery. The variety of flaps will be planned according to the defect size comparison between the bone and soft tissue, and ipsilateral upper limb function, and a proposed algorithm will be discussed.

Glenoid Component Loosening in Anatomic Total Shoulder Arthroplasty: Association between Radiological Predictors and Clinical Parameters—An Observational Study

The mechanisms of glenoid component loosening in anatomic total shoulder arthroplasty (aTSA) are still unclear, and it remains undetermined which specific radiographic features are associated with clinical outcomes. Patients with primary osteoarthritis who underwent aTSA with a stemless implant and a pegged glenoid between January 2011 and December 2016 were extracted from a local registry. Anteroposterior radiographs were evaluated at six, 12, 24 months, and five years post-TSA for lateral humeral offset (LHO), joint gap (JG), acromiohumeral distance (AHD), and radiolucency (modified Franklin score); 147 patients were included. Mixed-model linear regression was used. Both constant score (CS) and subjective shoulder value (SSV) markedly decreased at five years follow-up compared to one year (p < 0.001 for both). AHD, LHO, and JG all showed a consistent and statistically significant decline over time, with the joint gap decreasing by half. Consistently, smaller JG and AHD were correlated with lower SSV (p = 0.03 and p = 0.07, respectively). Massive loosening was associated with a 14.5 points lower SSV (p < 0.01). Finally, narrowing of the JG was significantly correlated with increased radiolucency (p < 0.001) and tended toward worse SSV (p = 0.06). In summary, radiographic parameters displaying medialization and cranialization after aTSA with a cemented pegged glenoid are useful predictors of impaired shoulder function.

The inflammatory response of the supraspinatus muscle in rotator cuff tear conditions

Rotator cuff (RC) disorders involve a spectrum of shoulder conditions from early tendinopathy to full-thickness tears leading to impaired shoulder function and pain. The pathology of RC disorder is, nonetheless, still largely unknown. Our hypothesis is that a supraspinatus (SS) tendon tear leads to sustained inflammatory changes of the SS muscle along with fatty infiltration and muscle degeneration, which are threshold markers for poor RC muscle function. The aim of this study was to determine the extent of this muscle inflammation in conjunction with lipid accumulation and fibrosis in RC tear conditions. We used proteomics, histology, electrochemiluminescence immunoassay, and quantitative polymerase chain reaction analyses to evaluate inflammatory and degenerative markers and fatty infiltration in biopsies from 22 patients undergoing surgery with repair of a full-thickness SStendon tear. Bioinformatic analysis showed that proteins involved in innate immunity, extracellular matrix organization, and lipid metabolism were among the most upregulated, whereas mitochondrial electronic transport chain along with muscle fiber function was among the most downregulated. Histologicanalysis confirmed changes in muscle fiber organization and the presence of inflammation and fatty infiltration. Inflammation appeared to be driven by a high number of infiltrating macrophages, accompanied by elevated matrix metalloprotease levels and changes in transforming growth factor-β and cytokine levels in the SS compared with the deltoid muscle. We demonstrated massive SS muscle inflammation after the tendon tear combined with fatty infiltration and degeneration. The regulation of tissue repair is thus extremely complex, and it may have opposite effects at different time points of healing. Inhibition or stimulation of muscle inflammation may be a potential target to enhance the outcome of the repaired torn RC.

Three-dimensional kinematic features in large and massive rotator cuff tears with pseudoparesis

Although massive rotator cuff tears occasionally lead to severe impairment of shoulder function, the criteria for losing the ability to elevate the arm are unclear. This study aimed to analyze the features of both tear size and 3-dimensional (3D) shoulder kinematics that correspondto the loss of the ability to elevate the arm in patients with large and massive rotator cuff tears. We prospectively enrolled patients with rotator cuff tears, including the supraspinatusand more than half of the subscapularis or more than two-thirds of the infraspinatus, without severe pain. A total of 13 patients (15 shoulders) were divided into 2 groups: 9 shoulders in the pseudoparesis (P) group and 6 shoulders in the non-pseudoparesis (NP) group. Fluoroscopic images were collected during active scapular-plane elevation, and 3D shoulder kinematics was analyzed using 2-dimensional-3D registration techniques. The radiographic findings and 3D kinematic results were compared between the groups. The correlation between tear size and 3D kinematics was also investigated. The most superior position of the humeral head center was significantly higher in the P group (6.7 ± 3.0 mm in P group vs. 3.6 ± 1.3 mm in NP group, P = .0321). Superior migration, which was defined as the most superior position > 5 mm, was significantly more frequent in the P group (7 shoulders and 1 shoulder in the P and NP groups, respectively; P = .0201). Thoracohumeral external rotation was significantly smaller in the P group (16° ± 31° in P group vs. 91° ± 21° in NP group, P < .0001). The total tear size and the tear sizes of the anterior and posterior rotator cuffs were significantly correlated with the superior (r = 0.68, P = .0056), anterior (r = 0.68, P = .0058), and posterior (r = -0.80, P = .0004) positions of the humeral head center. The tear size of the posterior rotator cuff also tended to be correlated with glenohumeralexternal rotation (r = -0.48, P = .0719). Anterior and posterior rotator cuff tears cause significant superior and anteroposterior translations of the humeral head, and posterior cuff tears may lead to loss of glenohumeral external rotation. With these abnormal kinematics, superior migration and loss of thoracohumeral external rotation were identified as features of pseudoparesis.

Arthroscopic and open partial arthroplasty for the treatment of focal grade IV cartilage defects of the humeral head.

Focal Outerbridge grade IV cartilage defects of the proximal humerus may lead to pain and an impaired shoulder function. In cases of failed operative or conservative treatment options such as intraarticular injections or arthroscopic microfracturing of the subchondral bone, partial arthroplasty of the humeral may restore the articular surface of the humeral head without altering the anatomy. This study evaluates mid-term results of open and arthroscopic partial resurfacing of the humeral head in the context of focal grade IV cartilage defects. Eighteen patients (f = 3, m = 15, mean age = 57.7years) out of 22 patients were available for follow-up after 65 (24-116) months. Thirteen patients were treated with a partial humeral head prosthesis in an open technique and five patients received a partial humeral head prosthesis in an arthroscopic technique. The patients were followed-up clinically using the Constant-Score, the ASES Score as well as the range of motion. Plain radiographs (anterior-posterior and axial view) were carried out for radiologic assessment. At follow-up the mean CS rated 79.5. The mean ASES Score was 85.8 points. Mean active forward flexion measured 163.8°, while mean active abduction was 160.0°. The average pain level on a visual analogue scale (VAS) made out 0.7 out of 10. Patients treated with an arthroscopically implanted prosthesis achieved a mean CS of 88.8 points and a mean ASES Score of 92.6 points. The patients with openly implanted prosthesis had a CS of 75.3 points and an ASES Score of 83 points. There were no intraoperative or immediate postoperative complications. Until the final follow-up one patient needed to be converted to total shoulder arthroplasty due to progressive glenohumeral osteoarthritis. Nine patients (50%) showed progressive glenohumeral osteoarthritis. Aseptic loosening of the implants was not observed. Partial arthroscopic or open arthroplasty of the humeral head is related to good functional results after mid-term follow-up. Resurfacing of the humeral head is a safe procedure without any implant-related complications. There is a risk for progression of glenohumeral osteoarthritis, which may require surgical revision with conversion to anatomic shoulder arthroplasty. Level IV (retrospective study).

Shoulder function after neck dissection: Assessment via a shoulder-specific quality-of-life questionnaire and active shoulder abduction

ObjectiveNeck dissection results in a high probability of postoperative shoulder functional impairment, even when the spinal accessory nerve is preserved. Therefore, surgeons must inform patients about the expected functional and qualitative recovery of shoulder function after surgery. MethodsThe present study included a prospective cohort of 66 patients (85 neck dissection sides) who underwent neck dissection between December 2015 and July 2017 at a single institution. The active shoulder abduction angles of the affected side and the patient-reported shoulder-specific quality-of-life recovery score of the Western Ontario Rotator Cuff (WORC) questionnaire were examined at 1, 3, 6, 9, and 12 months postoperatively. Additionally, the association between these outcomes and risk factors for shoulder impairment were investigated. ResultsThe average active shoulder abduction angles were significantly improved at 3 and 6 months postoperatively compared with 1 month postoperatively (96.5 ± 4.3° at 1 month versus 110.1 ± 4.7° at 3 months, p = 0.035, and versus 142.0 ± 4.6° at 6 months, p < 0.0001). The proportion of patients who were unable to abduct their shoulders by 150° or more was significantly lower at 6 months postoperatively (41.5%) compared with 1 month postoperatively (82.4%, p < 0.0001). The WORC score significantly improved from 60.4 ± 2.4% at 1 month postoperatively to 67.9 ± 2.6% at 6 months postoperatively (p = 0.036). Multivariate analysis revealed that postoperative radiotherapy was a significant risk factor for shoulder impairment at 3 and 6 months postoperatively (p = 0.003 and p = 0.027, respectively), and that level V dissection and head and neck irradiation were significant risk factors for a worse shoulder outcome at 6 and 9 months postoperatively (respective p values for level V dissection and head and neck irradiation were p = 0.049 and p = 0.030 at 6 months postoperatively, and p = 0.016 and p = 0.013 at 9 months postoperatively). ConclusionSatisfactory functional and qualitative recovery of shoulder function was achieved at 6 months after neck dissection. Postoperative radiotherapy was a predictor of poor shoulder function in the early postoperative period; both level V dissection and head and neck irradiation were predictors of poor shoulder function at 6 and 9 months after neck dissection.

Minimum 5-Year Clinical Outcomes, Survivorship, and Return to Sports after Hamstring Autograft Reconstruction for Sternoclavicular Joint Instability

Objectives:Instability of the sternoclavicular (SC) joint is a rare but potentially devastating pathology, particularly when it occurs in young or active patients, where it can lead to persistent pain and impairment of shoulder function. SC reconstruction using a hamstring tendon autograft is a commonly used treatment option, but mid-term results are still lacking. To assess clinical outcomes, survivorship, and return to sports rate after SC joint reconstruction using hamstring tendon autograft in patients suffering from SC joint instability. We hypothesized that SC joint reconstruction would result in good clinical outcomes, a high survivorship, and a high rate of return to sports.Methods:All patients who underwent SC joint reconstruction with a hamstring tendon autograft for SC joint instability, with a minimum 5-year follow up, were included. Patient reported outcomes were assessed prospectively by the use of the American Shoulder and Elbow Surgeons (ASES) Score, Single Assessment Numerical Evaluation (SANE) Score, Quick Disabilities of the Arm, Shoulder and Hand (DASH) Score, General heath physical component of the SF-12 (PCS) and patient satisfaction. Survivorship of reconstruction was defined as no further SC joint dislocation events or revision surgery. Return to sports and pain were assessed using a customized questionnaire.Results:22 SC joint reconstructions with a mean age of 31.3 (range 15.8 - 57.0 years) at the time of surgery were included. At final evaluation, 18 SC joint reconstructions with a mean follow up of 6.0 years (range 5.0 – 7.3 years) were eligible for minimum 5-year follow-up. All clinical outcome scores improved significantly pre- to postoperatively, ASES (50.0 to 91.0; p = .005), SANE (45.9 to 86.0; p = .007), QuickDASH (44.2 to 12.1; p = .003), and PCS (39.4 to 50.9; p = .001). Median postoperative satisfaction was 9 (range 7 - 10). The construct survivorship was 90% at 5-year follow-up. Two patients failed at 82 and 336 days postoperatively and were revised with revision SC joint reconstruction and capsulorrhaphy. Another patient had a superficial wound infection, which was debrided once, and resulted in a good clinical outcome. Of the patients who answered optional sports activity questionnaires, 17 (77%) shoulders participated in recreational or professional sports before injury. At final follow-up, 16/17 (94%) shoulders returned to their pre-injury level of sport or better. The VAS score for pain today (p = 0.004) and pain at its worst (p = 0.004) improved significantly pre- to postoperatively.Conclusions:SC joint reconstruction with hamstring tendon autograft for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and 90% survivorship at mid-term follow up. Furthermore, a reliable rate of return to previous level of sports was observed in this young and high-demanding patient population. Concerns in terms of advanced post-instability arthritis were not confirmed since a significant decrease in pain was found after minimum 5-year follow-up.

Risk factors of impairment of shoulder function after axillary dissection for breast cancer.

Postoperative shoulder joint dysfunction has been observed at a certain rate after breast cancer surgery with axillary lymph node dissection. The purposes of this study were to verify the feasibility and effects of home-based exercise using a DVD and clarify the target of intensive intervention with physiotherapy by identifying the factors that cause postoperative shoulder dysfunction. The study comprised 237 female patients who underwent breast cancer surgery with axillary lymph node dissection, whose data were acquired until 3months postoperatively. All patients were instructed to exercise at home using a DVD. Range of motion (ROM) of shoulder flexion and abduction and the disability of the arm, shoulder, and hand (DASH) score were measured before surgery, 1week and 1, 2, and 3months after surgery. As factors influencing the recovery of shoulder ROM at 3months after surgery, the presence or absence of radiation and factors up to 1month after surgery (age, body mass index, the relationship between operated side and dominant side of the hand, treatment modalities, and complications). Shoulder ROM and DASH scores had gradually recovered from 1week to 3months postoperatively. As the results of the multivariate analysis, the factors that were associated with the recovery of ROM of shoulder flexion at 3months were the side of surgery corresponding to the dominant hand (negative factor) and the presence of paresthesia at 1week postoperatively (positive factor) (p < 0.05). Radiation therapy and the side of surgery corresponding to the dominant hand were negative factors for the recovery of shoulder abduction (p < 0.01). Regarding the feasibility of the home exercise, 214/229 (93.4%), 172/210 (81.9%), and 139/206 (67.5%) of patients performed exercise at least once a day at 1, 2, and 3months after surgery, respectively. Our result indicated that the side of surgery corresponding to the dominant hand was the inhibiting factor for recovery for both shoulder flexion and abduction at 3months after surgery. Home-based exercise with DVD was considered feasible. For the verification of this effectiveness, a randomized control study should be planned in the future.

Functional outcome and tendon integrity of rotator cuff reconstruction after primary traumatic glenohumeral dislocation.

Rotator cuff tears (rct) subsequent to glenohumeral dislocation are relevant concomitant injuries, can lead to impaired shoulder function and increase risk of recurrent dislocation. The aim of this study was to determine the functional outcome, recurrent dislocation rate and tendon integrity after rotator cuff repair after primary traumatic shoulder dislocation. In this retrospective case series, 23 patients (age 56.4 years ± 6.3) who underwent a rotator cuff reconstruction after primary traumatic shoulder dislocation with confirmed combination of full-thickness RCT and Bankart lesion were enrolled after a minimum follow-up of 2years. Clinical outcome (age and gender adjusted Constant Murley Score (CMS), DASH, Rowe Score) (n = 23) and sonographic tendon integrity (n = 19) were studied. After a mean follow-up of 58 ± 32months, a CMS of 85.1% ± 14.7, DASH of 14.2 ± 20.5, and Rowe Score of 82.4 ± 15.2 indicated good functional outcome. In 4 of 19 patients (21.1%) a re-tear was found during sonographic evaluation. In 3 cases (13%), a revision was performed (2 × stiff shoulder, 1 × postoperative infection). One patient had a single traumatic re-dislocation (4.3%). Patients undergone reconstruction of the rotator cuff following a primary traumatic shoulder dislocation can achieve good functional results and a low rate of recurrent dislocation. Postoperative tendon integrity is comparable with known data about non traumatic tears.

Midshaft clavicle fracture following osteosynthesis with a hook plate: a retrospective case analysis.

The clavicle hook plate has been commonly used to treat distal clavicle fractures and acromioclavicular (AC) joint dislocations; however, midshaft clavicle fracture at the medial end of the hook plate remains an underestimated complication. We aimed to discover the risk factors for this complication and the influence of these risk factors on patients and to suggest preventive surgical techniques. We retrospectively reviewed the records of 150 patients with acute distal clavicle fractures or acute AC joint dislocations treated by internal fixation with a clavicle hook plate. The patient demographics, the occurrence of midshaft clavicle fracture at the medial end of the hook plate, and functional outcomes were analyzed. The functional outcomes were evaluated with the American Shoulder and Elbow Surgeons (ASES)Shoulder Score and grading of the Constant shoulder score after the hook plate was removed. In total, 17 patients had complicating midshaft clavicle fractures at the medial end of the hook plate. Elderly patients had a higher risk of developing this complication than young patients. The odds ratio was 4.4 (p < 0.05). The average ASES score and grading of Constant score of these patients were 74.1 and 16.3 points, respectively, which were significantly inferior to those of patients without complications (p < 0.001). The incidence of midshaft clavicle fractures following osteosynthesis with a clavicle hook plate was not negligible, especially in elderly patients. This complication may impair shoulder function and quality of life. Awareness of this complication and the risk factors for this complication reminds us to perform such operations with caution.

Minimum 5-Year Clinical Outcomes, Survivorship, and Return to Sports After Hamstring Tendon Autograft Reconstruction for Sternoclavicular Joint Instability

Background: Instability of the sternoclavicular (SC) joint is a rare but potentially devastating pathologic condition, particularly when it occurs in young or active patients, where it can lead to persistent pain and impairment of shoulder function. SC joint reconstruction using a hamstring tendon autograft is a commonly used treatment option, but midterm results are still lacking. Purpose/Hypothesis: The purpose of this study was to assess the clinical outcomes, survivorship, and return-to-sports rate after SC joint reconstruction using a hamstring tendon autograft in patients suffering from SC joint instability. We hypothesized that SC joint reconstruction would result in good clinical outcomes, high rate of survivorship, and a high rate of return to sports. Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent SC joint reconstruction with a hamstring tendon autograft for SC joint instability, with a minimum 5-year follow-up, were included. Patient-reported outcomes were assessed prospectively by the use of the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation (SANE) score, short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, 12-Item Short Form Health Survey (SF-12) physical component summary (PCS), and patient satisfaction. Survivorship of reconstruction was defined as no further revision surgery or clinical failure such as recurrent instability or subluxation events. Return to sports and pain were assessed using a customized questionnaire. Results: A total of 22 shoulders that underwent SC joint reconstruction, with a mean patient age of 31.3 years (range, 15.8-57.0 years) at the time of surgery, were included. At the final evaluation, 18 shoulders, with a mean follow-up of 6.0 years (range, 5.0-7.3 years), completed a minimum 5-year follow-up. All clinical outcome scores improved significantly from preoperatively to postoperatively: ASES (50.0 to 91.0; P = .005), SANE (45.9 to 86.0; P = .007), QuickDASH (44.2 to 12.1; P = .003), and SF-12 PCS (39.4 to 50.9; P = .001). Median postoperative satisfaction was 9 (range, 7-10). The construct survivorship was 90% at 5-year follow-up. There were 2 patients with failed treatment at 82 and 336 days postoperatively because of instability or pain who underwent revision SC joint reconstruction and capsulorrhaphy. Another patient had a superficial wound infection, which was debrided once and resulted in a good clinical outcome. Of the patients who answered optional sports activity questions, 15 (17 shoulders, 77%) participated in recreational or professional sports before the injury. At final follow-up, 14 patients (16 of 17 shoulders, 94%) returned to their preinjury level of sports. The visual analog scale score for pain today (P = .004) and pain at its worst (P = .004) improved significantly from preoperatively to postoperatively. Conclusion: SC joint reconstruction with a hamstring tendon autograft for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and 90% survivorship at midterm follow-up. Furthermore, 94% of this young and high-demand patient population returned to their previous level of sports. Concerns in terms of advanced postinstability arthritis were not confirmed because a significant decrease in pain was found after a minimum 5-year follow-up.

Shoulder Function After Cardioverter-Defibrillator Implantation: 5-Year Follow-up

Implantable cardioverter-defibrillator (ICD) represents the main tool for prevention of sudden cardiac death. Different kinds of postimplant complications have been described; however, little is known about shoulder functional impairment and its impact on quality of life. Patients with standard indications for elective prepectoral subcutaneous ICD insertion were enrolled during a 1-year period. The impact of ICD implantation on shoulder motility, pain, general disability, and quality of life was evaluated prospectively at baseline, and after 2 weeks, 3 months, 1 year, and 5 years using the Constant score, the Numeric Pain Rating Scale, the Disabilities of the Arm, Shoulder, and Hand scale, and the Short Form-36 Health Survey questionnaire. A total of 50 patients underwent insertion of single, dual chamber, or biventricular ICDs. Two weeks after implantation, functional impairment and mild pain were observed in ipsilateral shoulder movements, with a reduction in the Short Form-36 Health Survey score. Shoulder functional impairment improved at the third-month evaluations, with almost normalization at 1-year and 5-year assessments, as well as pain and quality of life. Prepectoral subcutaneous ICD implantation may be associated with ipsilateral shoulder functional impairment that regresses partially after 3 months and completely at 1-year and 5-year assessments. The less invasive implantation technique and the relatively small size of modern ICDs, independently from types and volumes, may be relevant to the degree of postimplantation shoulder functional impairment and recovery time. Shoulder function should be assessed at routine checks, especially soon after ICD implantation because of potential functional impairment and subsequent impact on quality of life.

Comminuted fractures of the proximal humerus - principles of the diagnosis, treatment and rehabilitation.

Comminuted fractures of the proximal humerus impair shoulder function, resulting in more or less severe disability. They rank among the most frequent fractures in adults, with incidence increasing with age and the degree of bone loss (osteoporosis). Among all currently used methods of stabilization of proximal humeral fractures, the best outcomes are afforded by angularly-stable plate fixation and interlocking or reconstructive intramedullary nailing. Both methods produce comparable results enabling bone union and restoration of limb functionality. Nevertheless, in elderly patients with advanced bone loss, in whom anatomical reduction of bone fragments is difficult or impossible, stabilization questionable and patient cooperation in the postoperative rehabilitation impossible to enforce, arthroplasty should be considered. Non-displaced or minimally displaced fractures may be treated conservatively by immobilizing the limb in an orthosis for three weeks. Nevertheless, the recommendations for operative interventions are being broadened, as stabilization eliminates the need to immobilize the limb, thus not affecting the patient's professional and social activities, enabling immediate rehabilitation, reducing the risk of joint stiffness and shortening recovery time.

Biomechanics of lower trapezius and latissimus dorsi transfers in rotator cuff–deficient shoulders

Irreparable posterosuperior rotator cuff tears cause pain and impaired shoulder function. Latissimus dorsi (LD) transfer has been proven to improve shoulder function, but lower trapezius (LT) transfer has recently been proposed as an alternative. This study aimed to compare the biomechanics of LD and LT transfers and how they are affected by different insertion sites. The Newcastle shoulder model was used to investigate the biomechanics of these 2 tendon transfers. Computed tomography data sets from 10 healthy subjects were used to customize the model, and virtual LD and LT transfers were performed on supraspinatus, infraspinatus, and teres minor insertion sites. Muscle moment arms and lengths were computed for abduction, forward flexion, and external rotation. The LT yields greater abduction moment arms compared with the LD when it is transferred to the native supraspinatus and infraspinatus insertion sites. However, they become adductors when transferred to the native teres minor insertion. Both muscles show strong external rotation moment arms, except for the LT with a supraspinatus insertion. Resting muscle strains were 0.21 (±0.03), 0.12 (±0.02), and 0.06 (±0.03) for the LD and 0.70 (±0.15), 0.61 (±0.13), and 0.58 (±0.13) for the LT for the supraspinatus, infraspinatus, and teres minor insertions, respectively. LT provided better abduction and external rotation moment arms when transferred to the infraspinatus insertion. LD performed better when transferred to the supraspinatus insertion. Overall, LT transfer showed a biomechanical advantage compared with LD transferbecause of stronger abduction moment arms. However, significantly larger muscle strains after LT transfer necessitatea tendon allograft to prevent muscle overtensioning.

Functional recovery after bilateral extended autologous latissimus dorsi breast reconstruction: A prospective observational study

The impact of unilateral extended autologous latissimus dorsi (EALD) flap harvest and axillary surgery on shoulder function has been well described, but the impact of bilateral EALD flap harvest has not been clearly defined nor is it clear whether reconstructions should be synchronous or staged. In this prospective observational study, patients undergoing bilateral EALD breast reconstruction (February 2003-December 2009) completed the disability, arm, shoulder and hand (DASH) questionnaire preoperatively and at five post-operative timepoints. Intensive shoulder physiotherapy was offered to those whose DASH score was >30 at 6 weeks or >20 at 12 weeks post-operatively. Sixty patients underwent bilateral EALD flap breast reconstruction (51 synchronous, 9 metachronous). Patients with pre-existing shoulder pathology (n = 1) and those who failed to return any post-operative DASH questionnaire (n = 10) were excluded from initial DASH analysis. However, these eleven patients were included in a separate analysis as an intention-to-treat analysis. Statistical analysis was performed using non-parametric, Friedman test and multiple comparison model. Forty-nine patients' DASH scores were analysed. DASH score initially increased after surgery and then returned to functionally normal within 3-6 months (median DASH: preoperative = 1 vs 6 weeks post-operation = 26, p=<0.001; vs 3months = 19, p=<0.001; vs 6 months = 13, p=<0.001); thereafter, the scores remained less than 12 (p=<0.001). Median DASH score after synchronous reconstruction was not higher than that after metachronous reconstructions, although the metachronous sample size was small. With appropriate patient selection and intensive physiotherapy, bilateral EALD breast reconstruction does not appear to cause significant long-term impairment of shoulder function, and patients can now be counselled about the likely timecourse of shoulder recovery. There seems no reason to stage bilateral reconstruction to reduce shoulder morbidity.

Breast cancer surgery: when less is more

This brief review traces the evolution of breast cancer surgery from radical mastectomy (MTX) to breast conserving therapy (BCT) where wide local excision (WLE) of the cancer is combined with whole breast irradiation. The role of sentinel lymph node biopsy (SLNB) to assess the axilla as an alternative to more extensive axillary lymph node dissection (ALND) is examined. This review is a contemporary evaluation of these procedures (BCT, SLNB) and their impact on survival and in reduction of morbidity, and shows that local recurrence of breast cancer (BC) after BCT has been reduced to < 5% at 10-year follow-up when guidelines that excision margins should be free of microscopic cancer are followed and where patients receive whole breast irradiation together with systemic therapy after WLE. Over the past decade, studies of women with early BC entered on the SEER data base, the California Cancer Register and the Norwegian Cancer Registry have shown that overall survival (OS) and disease specific survival (DSS) are significantly better after BCT than following MTX. The improved survival after BCT compared to MTX cannot be attributed to radiation alone. The critical difference between these two procedures is the extent of dissection. Experimental studies using animal models have provided convincing evidences that the more extensive the tissue trauma, the greater the postoperative inflammatory cascade. This cascade of cytokines and growth factors impairs humoral immunity and enhances cancer cell survival and growth. The reduction in tissue trauma in patients undergoing BCT is a likely explanation for their improved survival. Compared to ALND, SLNB results in less lymphoedema, sensory loss and impaired shoulder function. For the clinically negative axilla, normal on palpation and imaging, SLNB is accurate in both the initial assessment and after neoadjuvant chemotherapy (NAC).

A Mouse Model of Delayed Rotator Cuff Repair Results in Persistent Muscle Atrophy and Fatty Infiltration

Background: Rotator cuff (RC) tears are common tendon injuries seen in orthopaedic patients. Successful repair of large and massive RC tears remains a challenge due to our limited understanding of the pathophysiological features of this injury. Clinically relevant small animal models that can be used to study the pathophysiological response to repair are limited by the lack of chronic repair models. Purpose: To develop a highly clinically relevant mouse model of delayed RC repair. Study Design: Controlled laboratory study. Methods: Three-month-old C57BL/6J mice underwent unilateral supraspinatus (SS) and infraspinatus (IS) tendon tear with immediate, 2-week delayed, or 6-week delayed tendon repair. Animals with no repair or sham surgery served as controls. Gait analysis was conducted to measure shoulder function at 2 weeks and 6 weeks after surgery. Animals were sacrificed 6 weeks after the last surgery. Shoulder joint, SS, and IS muscles were harvested and analyzed histologically. Ex vivo mechanical testing of intact and repaired SS and IS tendons was conducted. Reverse-transcriptase polymerase chain reaction was performed on SS and IS muscles to quantify atrophy, fibrosis, and fatty infiltration–related gene expression. Results: Histological and tendon mechanical testing showed that torn tendons could be successfully repaired as late as 6 weeks after transection. However, significant atrophy and fatty infiltration of muscle, with impaired shoulder function, were persistent in the 6-week delayed repair group. Shoulder function correlated with the severity of RC muscle weight loss and fatty infiltration. Conclusion: We successfully developed a clinically relevant mouse model of delayed RC repair. Six-week delayed RC repair resulted in persistent muscle atrophy and fatty infiltration with inferior shoulder function compared with acute repair. Clinical Relevance: Our novel mouse model could serve as a powerful tool to understand the pathophysiological and cellular/molecular mechanisms of RC muscle and tendon degeneration, eventually improving our strategies for treating and repairing RC tears.