Osteointegration of a Biocomposite Suture Anchor After Arthroscopic Shoulder Labral Repair.

PURPOSE: To evaluate osteoconductivity of a poly-L-lactide co-glycolide (PLG)-calcium sulfate (CS)-ß-tricalcium phosphate (ß-TCP) biocomposite suture anchor after arthroscopic shoulder labral repair. METHODS: The subjects of this study were patients who participated in a clinical trial for acquisition of marketing approval of a PLG-CS-ß-TCP biocomposite anchor in Japan. They underwent arthroscopic labral repair using the anchor, and computed tomographic (CT) images of the glenoid were obtained 2 years after surgery. Osteoconductivity at the anchor sites was evaluated with the CT images using the established ossification quality score. Shoulder function scores including the Rowe score and Japanese Shoulder Society shoulder instability score were also assessed 2 years after surgery. RESULTS: CT images and functional scores were obtained from 37 patients, comprising 29 men and 8 women with a mean age of 29 years (range, 25-33 years) at surgery. A total of 148 anchors were implanted in the 37 shoulders. Osteoconductivity was seen in 133 of 148 anchor sites (90.0%) 2 years after implantation. No significant differences in osteoconductivity were found by anchor diameter or position. The Rowe score significantly improved from 39.9 points (95% confidence interval [CI], 33.8-45.9 points) preoperatively to 96.6 points (95% CI, 95.1-98.1 points) at 2 years postoperatively (P < .001). The Japanese Shoulder Society shoulder instability score also significantly improved, from 63.1 points (95% CI, 58.4-67.7 points) preoperatively to 96.3 points (95% CI, 94.7-97.8 points) at 2 years postoperatively (P < .001). CONCLUSIONS: Biocomposite suture anchors made of PLG, CS, and ß-TCP exhibited some osteoconductivity 2 years after arthroscopic labral repair, as well as good clinical outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Tuberosity-overlapping Fixation of the Humeral Shaft in Humeral Head Replacement Surgery.

The fixation technique of bony fragments is crucial for the bone union of the tuberosities after humeral head replacement (HHR) for a comminuted fracture of the proximal humerus. To increase the bone union rate, we reduce tuberosities to overlap on the humeral shaft by approx. 1 cm and fix them with cable wire. Herein, we retrospectively investigated the clinical and radiographic outcomes of our procedure. Twenty-six patients who underwent cementless HHR for the treatment of comminuted fractures of the proximal humerus were investigated. The Constant-Murley score, active shoulder mobility, and bone union rate were evaluated. The mean duration of follow-up was 56.3 months (range 24-197). At the final follow-up, the average Constant-Murley score was 58 (range 40-76). Forward elevation was 126° on average (range 35°-180°). Twenty-three cases (88%) showed bone union between the tuberosities and the shaft at an average follow-up of 4.1 months (range 4-5 months) after surgery. Non-union was noted in 1 case, and bone resorption was noted in 2 cases. The bone union rate and the clinical outcome of our procedure were relatively favorable.

Advantages of arthroscopic transosseous suture repair of the rotator cuff without the use of anchors.

BACKGROUND: Although arthroscopic anchor suturing is commonly used for rotator cuff repair and achieves good results, certain shortcomings remain, including difficulty with reoperation in cases of retear, anchor dislodgement, knot impingement, and financial cost. In 2005, we developed an anchorless technique for arthroscopic transosseous suture rotator cuff repair. DESCRIPTION OF TECHNIQUE: After acromioplasty and adequate footprint decortication, three K-wires with perforated tips are inserted through the inferior margin of the greater tuberosity into the medial edge of the footprint using a customized aiming guide. After pulling the rotator cuff stump laterally with a grasper, three K-wires are threaded through the rotator cuff and skin. Thereafter, five Number 2 polyester sutures are passed through three bone tunnels using the perforated tips of the K-wires. The surgery is completed by inserting two pairs of mattress sutures and three bridging sutures. METHODS: We investigated the retear rate (based on MR images at least 1 year after the procedure), total score on the UCLA Shoulder Rating Scale, axillary nerve preservation, and issues concerning bone tunnels with this technique in 384 shoulders in 380 patients (174 women [175 shoulders] and 206 men [209 shoulders]). Minimum followup was 2 years (mean, 3.3 years; range, 2-7 years). Complete followup was achieved by 380 patients (384 of 475 [81%] of the procedures performed during the period in question). The remaining 91 patients (91 shoulders) do not have 1-year postsurgical MR images, 2-year UCLA evaluation or intraoperative tear measurement, or they have previous fracture, retear of the rotator cuff, preoperative cervical radiculopathy or axillary nerve palsy, or were lost to followup. RESULTS: Retears occurred in 24 patients (24 shoulders) (6%). The mean overall UCLA score improved from a preoperative mean of 19.1 to a score of 32.7 at last followup (maximum possible score 35, higher scores being better). Postoperative EMG and clinical examination showed no axillary nerve palsies. Bone tunnel-related issues were encountered in only one shoulder. CONCLUSIONS: Our technique has the following advantages: (1) reoperation is easy in patients with retears; (2) surgical materials used are inexpensive polyester sutures; and (3) no knots are tied onto the rotator cuff. This low-cost method achieves a low retear rate and few bone tunnel problems, the mean postoperative UCLA score being comparable to that obtained by using an arthroscopic anchor suture technique.

A radiographic classification of massive rotator cuff tear arthritis.

BACKGROUND: In 1990, Hamada et al. radiographically classified massive rotator cuff tears into five grades. Walch et al. subsequently subdivided Grade 4 to reflect the presence/absence of subacromial arthritis and emphasize glenohumeral arthritis as a characteristic of Grade 4. QUESTIONS/PURPOSES: We therefore determined (1) whether patient characteristics and MRI findings differed between the grades at initial examination and final followup; (2) which factors affected progression to a higher grade; (3) whether the retear rate of repaired tendons differed among the grades; and (4) whether the radiographic grades at final followup differed from those at initial examination among patients treated operatively. PATIENTS AND METHODS: We retrospectively reviewed 75 patients with massive rotator cuff tears. Thirty-four patients were treated nonoperatively and 41 operatively. RESULTS: Patients with Grade 3, 4, or 5 tears had a higher incidence of fatty muscle degeneration of the subscapularis muscle than patients with Grade 1 or 2 tears. In 26 patients with Grade 1 or 2 tears at initial examination, duration of followup was longer in patients who remained at Grade 1 or 2 than in those who progressed to Grade 3, 4, or 5 at final followup. The retear rate of repaired supraspinatus tendon was more frequent in Grade 2 than Grade 1 tears. In operated cases, radiographic grades at final followup did not develop to Grades 3 to 5. CONCLUSIONS: We believe cuff repair should be performed before acromiohumeral interval narrowing. Our observations are consistent with the temporal concepts of massive cuff tear pathomechanics proposed by Burkhart and Hansen et al. LEVEL OF EVIDENCE: Level III, Therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Four-segment classification of proximal humeral fractures revisited: a multicenter study on 509 cases.

BACKGROUND: The 4-segment classification of Neer (1970) was revised in 2002 with the inclusion of valgus-impacted fractures. However, the range of possible fracture types covered by this classification is not clear. With the aim to clarify actual fracture patterns of the proximal humerus, a retrospective, multicenter study was conducted. METHODS: We retrospectively reviewed 509 cases for which anteroposterior and trans-scapular lateral views had been taken at the time of injury. Initially, three examiners from three facilities, independently read the radiographs of each case. In the second and third phases, for more difficult cases, consensus opinions were reached. RESULTS: We found that 501 (98%) of the 509 fractures had an appropriate category in the revised Neer classification. There were 185 cases (36%) of one-part fractures, followed by 156 cases (31%) of 2-part surgical neck fracture, 60 cases (12%) of 2-part greater tuberosity fracture (dislocation included), 45 cases (8.8%) of 3-part fracture involving the greater tuberosity and the surgical neck (dislocation included), 31 cases (6.1%) of 4-part fracture (dislocation included), and 17 cases (3.3%) of valgus-impacted fracture.Eight fractures (1.6%) could not be classified with the revised Neer classification. They were "3-part" fractures in terms of the number of displaced segments but had a complete anatomic neck fracture. CONCLUSION: We conclude that it would be appropriate to use the revised Neer classification in clinical practice. We would emphasize that, when there are 3 displaced segments, close attention should be paid to the fracture line on the anatomic neck. LEVEL OF EVIDENCE: Level 4; Diagnostic study, case series.

Humeral shortening and inferior subluxation as sequelae of septic arthritis of the shoulder in neonates and infants.

BACKGROUND: Although humeral shortening as a sequel of septic arthritis of the shoulder in infants has been reported in previous studies, functional disorders of the shoulder resulting from humeral shortening have not yet been clarified. In this study, we retrospectively investigated the long-term outcome of septic arthritis of the shoulder in neonates and infants and examined the relationship between growth disturbance of the humerus and decreased range of motion with respect to glenohumeral joint laxity. METHODS: We reviewed the cases of fifteen patients (sixteen shoulders) with an age of a few days to 2.6 years at the onset of the disease who were followed from 5.0 to 17.9 years. We noted the initial treatment method and evaluated humeral length and shoulder function at the time of the final follow-up. For the final treatment results, we classified the shoulders with normal findings on radiographs as Grade I, those with humeral head deformity as Grade II, and those with humeral head deformity with inferior subluxation as Grade III. RESULTS: Primary treatment included arthrotomy in ten shoulders. The delay between the onset of the disease and surgery ranged from three to twenty-six days. At the time of the final follow-up, the results were Grade I in five shoulders, Grade II in six shoulders, and Grade III in five shoulders. The mean humeral shortening was 0.1 cm for Grade-I shoulders, 0.9 cm for Grade-II shoulders, and 7.3 cm for Grade-III shoulders. All Grade-III shoulders had >or=3 cm of shortening, and four of the five Grade-III shoulders showed limitation of elevation (abduction of <130 degrees ). None of the Grade-III shoulders had undergone arthrotomy within ten days after the onset of the disease. CONCLUSIONS: Inferior subluxation of the humeral head related to shoulder dysfunction resulting from early childhood septic arthritis accompanied humeral shortening of >or=3 cm and was only observed in patients who did not undergo arthrotomy of the shoulder within ten days after the onset of the infection.