Reliability of scapular classification in examination of professional baseball players.

BACKGROUND: Clinically evaluating the scapulothoracic joint is challenging. To identify scapular dyskinesis, clinicians typically observe scapular motion and congruence during self-directed upper extremity movements. However, it is unclear whether this method is reliable. QUESTIONS/PURPOSES: We therefore determined the interrater reliability of a scapular classification system in the examination of professional baseball players. METHODS: Seventy-one healthy uninjured professional baseball players between the ages of 18 and 32 years volunteered to participate. We used a digital video camera to film five repetitions of scapular plane elevation while holding a 2-pound weight. Four examiners then independently classified the motions on video into one of four types. Interrater reliability analysis using the kappa (k) statistic was performed for: (1) classifying each scapula into one of the four types; (2) classifying each scapula as being abnormal (Types I-III) or normal (Type IV); and (3) classifying both scapula as both being symmetric (both normal or both abnormal) or asymmetric (one normal, one abnormal). RESULTS: We found low reliability for all analyses. In classifying each scapula as one of the four types, reliability was k = 0.245 for the left limb and k = 0.186 for the right limb. When considering the dichotomous classifications (abnormal versus normal), reliability was k = 0.264 for left and k = 0.157 for right. For bilateral symmetry/asymmetric, reliability was k = 0.084. CONCLUSION: We found low reliability of visual observation and classification of scapular movement. CLINICAL RELEVANCE: Current evaluation strategies for evaluating subtle scapular abnormalities are limited. LEVEL OF EVIDENCE: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Partial Superior Capsular Reconstruction to Augment Arthroscopic Repair of Massive Rotator Cuff Tears Using Autogenous Biceps Tendon: Effect on Retear Rate.

BACKGROUND: Massive rotator cuff tears have a high incidence of postoperative retear that can reach 90%. It is still unclear which intervention may reduce the incidence of retear and improve the functional and clinical outcomes. PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the clinical and structural outcomes at 2 years after repair of reparable massive rotator cuff tears with and without the use of partial superior capsular reconstruction (pSCR), using the autologous long head of the biceps tendon (LHBT) as a graft. It was hypothesized that augmentation with a pSCR would decrease retear rates. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors compared arthroscopic repair of massive posterosuperior rotator cuff tears with and without augmentation using the LHBT for pSCR between 2015 and 2017. After applying the selection criteria, 106 patients were included in the study and distributed into 2 groups of 50 and 56 patients. Patients in the first group (50 patients) underwent arthroscopic repair without use of the LHBT (AR group), and patients in the second group (56 patients) underwent arthroscopic repair with use of the LHBT for pSCR (AR-LHBT group). The structural outcome was evaluated by ultrasound at 2 years of follow-up. Function and pain were evaluated preoperatively and at the 2-year follow-up using the American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS). Pre- and postoperative active range of motion, including forward elevation, external rotation, and abduction, were also documented. RESULTS: No significant differences were found between groups regarding the baseline characteristics. After 24 months, both groups showed significant improvement from preoperative ASES scores, VAS score, and active range of motion (P < .01 for all). Patients in the AR-LHBT group showed significant improvements in postoperative functional and pain scores compared with the AR group in all measurements at the 2-year follow-up (ASES score: 77.23 ± 7.45 vs 71.04 ± 9.28, P < .01; VAS score: 1.64 ± 1.03 vs 2.12 ± 1.06, P < .01). Final range of motion was significantly increased for the AR-LHBT group for forward elevation (155 [interquartile range {IQR}, 150-160] vs 150 [IQR, 140-170]; P < .01) and abduction (150 [IQR, 140-157.5] vs 120 [IQR, 100-140]; P < .01), but external rotation was significantly greater for the AR group (54.43 ± 10.55 vs 59.5 ± 10.55; P < .01). Postoperative ultrasonography at the 2-year follow-up revealed a higher retear rate in the AR group than in the AR-LHBT group (46% vs 14%; P < .01). CONCLUSION: Use of the LHBT for pSCR to augment massive rotator cuff tears resulted in markedly lower retear rates and modestly improved pain and function outcomes compared with repair alone.

PERCEIVED SELF-REPORT OF EFFORT DURING ROTATOR CUFF & SCAPULAR REHABILITATIVE EXERCISE IN PATIENTS AFTER SHOULDER SURGERY.

BACKGROUND: Rehabilitation following shoulder surgery involves the use of resistive exercise but dosing of these -exercises historically employs multiple sets of pre-determined repetitions and few reports document the perceived effort encountered by patients during these exercises for both elastic resistance and free-weights. The OMNI-Resistance Exercise Scale (OMNI-RES) has been tested and applied as a measure of perceived exertion (RPE) for resistive exercise but has not gained widespread acceptance as an optimal method for physical therapists to document RPE during rehabilitation of shoulder surgery. PURPOSE: To generate descriptive values of RPE encountered during common shoulder exercises of varying resistance in patients following shoulder surgery as well as provide a comparative analysis between perceived exertion ratings of similar exercise movement patterns using elastic and traditional isotonic resistance. STUDY DESIGN: Descriptive Cross-sectional Cohort. METHODS: Sixty-six subjects (mean age 53.3 + 12.8 years) were included in this study following shoulder surgery (RC repair n=22, labral repair n=10, SA n=34). Perceived exertion using the OMNI-RES was recorded during performance of seven rotator cuff and scapular rehabilitation exercises at 6- and 12-weeks following surgery. RESULTS: Mean RPE using OMNI-RES in combined surgical groups ranged between 3.6 and 5.7 (mean = 4.50 + 2.1) across all seven exercises (scale 0 = very easy to 10 = extremely hard). From the external rotation (ER) exercise pair, paired t-tests revealed standing ER w/ Thera-band® (ERB) had a significantly higher OMNI-RES score versus sidelying ER w/ cuff weight (SLERW) (mean: 5.13 vs 4.41, p = 0.001) while the extension exercise pair consisting of standing shoulder extension w/ band (EXTB) and prone extension w/ cuff weight (PEXTW) showed no significant difference in OMNI-RES score (mean: 3.54, 3.67, p = 0.626). CONCLUSION: Commonly prescribed resistance exercise in the rehabilitation following shoulder surgery show light-moderate ratings of perceived exertion at both 6 & 12 week post-operative timepoints across three surgical procedures. LEVEL OF EVIDENCE: 3b.

Severe chondrolysis after shoulder arthroscopy: a case series.

HYPOTHESIS: Chondrolysis has been observed after shoulder arthroscopy and results in severe glenohumeral complications. MATERIALS AND METHODS: Twenty three cases of post-arthroscopic glenohumeral chondrolysis, occurring between 2005-2006, are reported following a variety of arthroscopic shoulder procedures. Presenting complaints, signs and symptoms, associated operative findings, and potential etiological factors are reviewed. Management options are summarized. RESULTS: Of the 23 cases of chondrolysis identified in our practice over a two year period, 14 occurred in patients following labral repair using a bioabsorbable device. Seventeen of the 23 patients used a high volume intra-articular pain pump for 48 hours after surgery. Seven of the 23 cases had documented use of a thermal probe. Four cases occurred in shoulders with no reported use of fixation anchors, pain pumps, or thermal probes. All cases had at least a 20 cc intra-articular bolus injection of 0.25% bupivicaine with epinephrine. DISCUSSION: This case series identifies several common factors that could be responsible for post-arthroscopic glenohumeral chondrolysis. No single mechanism can be implicated based on the results of this study. Although strong concerns are raised over the use of intra-articular local anesthetics, glenohumeral chondrolysis appears to be an unfortunate convergence of multiple factors that may initiate rapid dissolution of articular cartilage and degenerative changes. CONCLUSION: Chondrolysis is a devastating complication of arthroscopic shoulder surgery that can result in long-term disabling consequences. Further research is required to specifically identify causative factors. Until this is a available, we strongly advise against the use of large doses of intra-articular placement of local anesthetics.

Humeral resurfacing hemiarthroplasty with meniscal allograft in a young patient with glenohumeral osteoarthritis.

STUDY DESIGN: Case report. BACKGROUND: Management of glenohumeral joint osteoarthritis in young, active patients is challenging due to the significant functional limitations and progression of the disease, coupled with the limited lifespan of prosthetic implants presently in use. The purpose of this report is to present the detailed rehabilitation program and outcome of a patient who suffered an initial glenohumeral dislocation and, following multiple surgical interventions, required shoulder hemiarthroplasty and biologic glenoid resurfacing to return to function. CASE DESCRIPTION: An objectively based rehabilitation protocol was used for this patient following shoulder hemiarthroplasty. Data collected included passive and active range of motion, isometric rotational strength, and functional outcome scores to include the Single Assessment Numeric Evaluation (SANE) and American Shoulder Elbow Surgeons (ASES) outcome measures. OUTCOMES: Progressive improvements in active and passive range of motion were documented at numerous points during postoperative rehabilitation, including 1 and 2 years postoperatively. The patient's initial functional outcome scores improved from 2/100 to 90/100 in the SANE and from 17/100 to 85/100 for the ASES rating scales. At 2 years postsurgery the SANE score was 60/100 and ASES 68/100. DISCUSSION: Early postoperative range of motion exercises performed in a range protecting the subscapularis, coupled with a progressive program of rotator cuff and scapular strengthening exercises, resulted in decreased pain, improved range of motion, and return to work in a limited capacity following hemiarthroplasty with biologic glenoid resurfacing. Further research in series of patients following this procedure will help to establish optimal treatment guidelines and prognosis for young active patients with severe glenohumeral joint osteoarthritis. LEVEL OF EVIDENCE: Therapy, level 4.

Descriptive report of shoulder range of motion and rotational strength 6 and 12 weeks following rotator cuff repair using a mini-open deltoid splitting technique.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To measure short-term postsurgery glenohumeral internal rotation and external rotation strength, shoulder range of motion (ROM), and subjective self-report ratings following mini-open rotator cuff repair of full-thickness rotator cuff tears. BACKGROUND: Physical therapists provide rehabilitation for patients following mini-open rotator cuff repair. Long-term outcome studies have reported a high percentage of good and excellent results following surgery; however, little has been published regarding the immediate short-term results of this procedure, during which the patient is under the direct care of the physical therapist. MATERIALS AND METHODS: Charts from 11 female and 26 male patients, with a mean +/- SD age of 57.3 +/- 9.9 years, were reviewed following rotator cuff repair, using an arthroscopically assisted mini-open deltoid-splitting approach. All patients underwent postsurgery rehabilitation by the same therapist using a standard protocol. Retrospective chart review was used to obtain descriptive profiles of shoulder joint ROM at 6 and 12 weeks postsurgery and isokinetically assessed shoulder strength at 12 weeks postsurgery. RESULTS: For the postsurgical shoulder, ROM deficits ranging between 5 degrees to 7 degrees were measured for shoulder abduction and external rotation and internal rotation at 90 degrees of abduction. The postsurgical extremity had greater flexion ROM (9 degrees ) compared to the contralateral side. Isokinetic external rotation strength deficits of 5% to 7% were present at 12 weeks postsurgery, with 2% to 11% greater internal rotation shoulder strength on the operative extremity, when compared to the other side. Patients completed the self-report section of the modified American Shoulder Elbow Surgeons (ASES) Rating Scale at 12 weeks postsurgery and scored a mean of 38.7/45.0 points. CONCLUSION: The application of early ROM and progressive strengthening following mini-open rotator cuff repair allows for the successful return of ROM and strength 12 weeks postsurgery. The results of this study provide objective data for both shoulder ROM and strength at time points during which patients are traditionally receiving physical therapy following surgery.

Muscular activation during plyometric exercises in 90° of glenohumeral joint abduction.

BACKGROUND: Plyometric exercises are frequently used to increase posterior rotator cuff and periscapular muscle strength and simulate demands and positional stresses in overhead athletes. The purpose of this study was to provide descriptive data on posterior rotator cuff and scapular muscle activation during upper extremity plyometric exercises in 90° of glenohumeral joint abduction. HYPOTHESIS: Levels of muscular activity in the posterior rotator cuff and scapular stabilizers will be high during plyometric shoulder exercises similar to previously reported electromyographic (EMG) levels of shoulder rehabilitation exercises. STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty healthy subjects were tested using surface EMG during the performance of 2 plyometric shoulder exercises: prone external rotation (PERP) and reverse catch external rotation (RCP) using a handheld medicine ball. Electrode application included the upper and lower trapezius (UT and LT, respectively), serratus anterior (SA), infraspinatus (IN), and the middle and posterior deltoid (MD and PD, respectively) muscles. A 10-second interval of repetitive plyometric exercise (PERP) and 3 repetitions of RCP were sampled. Peak and average normalized EMG data were generated. RESULTS: Normalized peak and average IN activity ranged between 73% and 102% and between 28% and 52% during the plyometric exercises, respectively, with peak and average LT activity measured between 79% and 131% and between 31% and 61%. SA activity ranged between 76% and 86% for peak and between 35% and 37% for average activity. Muscular activity levels in the MD and PD ranged between 49% and 72% and between 12% and 33% for peak and average, respectively. CONCLUSION: Moderate to high levels of muscular activity were measured in the rotator cuff and scapular stabilizers during these plyometric exercises with the glenohumeral joint abducted 90°.

Glenohumeral joint total rotation range of motion in elite tennis players and baseball pitchers.

UNLABELLED: The amount of glenohumeral joint internal and external rotation used during overhead sport activities has been measured experimentally by sports scientists. Clinical measurement of glenohumeral joint internal and external rotation using goniometry is an integral part of a shoulder evaluation after injury or surgery or during preseason or preventative musculoskeletal screenings. PURPOSE: This study measured glenohumeral joint internal and external rotation in two groups of unilaterally dominant upper extremity athletes to compare the total arc of rotational range of motion between the dominant and nondominant extremities. METHODS: A total of 163 elite athletes (117 male junior tennis players and 46 male baseball pitchers) were measured for glenohumeral joint internal and external rotation at 90 degrees of abduction. Total rotation range of motion was calculated by summing internal and external rotation measures in each extremity. RESULTS: An ANOVA with post hoc testing revealed no significant difference (P > 0.05) between extremities in baseball pitchers for total rotation range of motion (145.7 vs 146.9), whereas significantly less (P < 0.001) dominant arm total rotation range of motion was identified in the elite junior tennis players (149.1 vs 158.2). CONCLUSION: This study has identified unique glenohumeral joint rotational patterning in unilaterally dominant upper extremity athletes that has ramifications for rehabilitation after injury and for both injury prevention and performance enhancement.

Radiofrequency electrothermal shrinkage of the anterior cruciate ligament.

The efficacy of electrothermal collagen shrinkage in the treatment of patients with anterior cruciate ligament laxity was evaluated. Eighteen patients who had continuity of the anterior cruciate ligament but had symptomatic laxity were treated with arthroscopic electrothermal shrinkage of the anterior cruciate ligament using a monopolar radiofrequency probe. The mean length of follow-up in patients whose stability was maintained was 20.5 months. Seven of the patients had undergone previous reconstruction, four with patellar tendon graft and three with quadrupled hamstring tendon graft. Laxity was chronic in nine patients and acute in nine. The KT-1000 arthrometer results at 1 month postoperatively revealed decreased anterior excursion, with an average side-to-side difference of 1.9 mm. However, 11 patients had a failed result at an average 4.0 months. Of the seven patients with successful results, six had native ligaments and had been treated for acute laxity and one had a patellar tendon graft and had been treated for chronic laxity. Even with the short-term follow-up in our study, it is evident that thermal shrinkage using radiofrequency technology has limited application for patients with anterior cruciate ligament laxity. Although it may be useful in treating patients with an acutely injured native anterior cruciate ligament, further study is needed to see if the ligament stretches out over time or is at increased risk of reinjury.

Anionic N,O-ligated Pd(II) complexes: highly active catalysts for alcohol oxidation.

There is a need to develop effective catalytic methods for alcohol oxidation. Pd(II) complexes have shown great promise as catalysts, however a comparatively small number of ligands have been reported so far. Herein we report the use of commercially available anionic N,O-ligands to produce highly active catalysts.

Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age.

BACKGROUND: Cementless humeral resurfacing arthroplasty is a bone-conserving arthroplasty option for patients with glenohumeral arthritis. It has been successful in the older patient population. However, data regarding the results of arthroplasty in younger, more active patients are lacking. We report the two-year results of this procedure in active patients who were less than fifty-five years of age. METHODS: We reviewed prospectively collected clinical data on a series of thirty-six patients under fifty-five years of age with end-stage glenohumeral arthrosis, but without osteonecrosis, who had undergone a cementless humeral resurfacing hemiarthroplasty performed by a single surgeon. All patients were followed for a minimum of two years. We assessed pain, function, and patient satisfaction and documented all complications. Radiographs were evaluated for implant loosening. RESULTS: The thirty-six patients had a mean age of 42.3 years and were followed for a mean of 38.1 months. Scores measured with a visual analog pain scale, the Single Assessment Numeric Evaluation (SANE) scale, and the American Shoulder and Elbow Surgeons (ASES) scale all improved significantly from preoperatively to two years postoperatively (p < 0.001). Complications included one traumatic subscapularis rupture at six weeks, three cases of arthrofibrosis, and one deep hematoma. No obvious radiographic evidence of loosening was noted at the time of the latest follow-up. One shoulder was converted to a stemmed total shoulder arthroplasty at twenty-four months because of pain, but the implant was not loose at the revision. The remaining thirty-five patients were satisfied with the outcome at the time of the latest follow-up and had returned to their desired activity. CONCLUSIONS: Cementless humeral resurfacing arthroplasty is a viable treatment option for younger, active patients. Early results indicate that the desired function and pain relief can be expected. Implant loosening and glenoid wear do not appear to be concerns in the short term despite the high activity levels of many patients. Long-term follow-up is needed to determine if these results persist.

Intrarater and interrater reliability of a manual technique to assess anterior humeral head translation of the glenohumeral joint.

The purpose of this study was to determine the intrarater and interrater reliability of a manual anterior humeral head translation test. Fifteen subjects were positioned lying in a supine position with their identity shielded from examiners. A standard manual anterior humeral head translation test was performed and repeated with the glenohumeral joint in 90 degrees of elevation in the scapular plane, with use of the grading method proposed by Altchek and Dines in 1993. Reliability was assessed with the coefficient of agreement and kappa statistic. Intrarater reliability was 81.4% comparing grade I and II translation. This decreased to 54% when examiners distinguished between grades I, I+, II, and II+. Interrater reliability for the same comparisons was 70.4%, decreasing to 37.3%. On the basis of these data, the technique of manually assessing anterior humeral head translation studied has poor overall interrater reliability and only fair intrarater reliability. The test-retest accuracy of humeral head translation is enhanced when examiners only determine the relationship of the humeral head relative to the glenoid rim.