Shoulder assessment by smartphone: a valid alternative for times of social distancing.

BACKGROUND: The delivery of orthopaedic care via telemedicine services has the potential to promote accessibility and decrease medical care expenses, while facilitating the control of infectious disease spreading. The purpose of this study was to assess agreement regarding diagnosis, recommended course of management and the perceived need for additional diagnostic testing between a video examination (VE) and a face to face (FTF) assessment of patients with shoulder disorders. METHODS: Forty-seven (18 females) patients presenting to a shoulder surgery clinic were assessed consecutively by VE and a FTF examination. All assessments were conducted by a shoulder specialist. Agreement regarding the established diagnosis, the recommended course of management and the need for additional diagnostic tests was assessed using percent agreement and kappa (95% CI) coefficient. Differences in the content, duration and satisfaction between the two examination modes were also assessed. RESULTS: Percent agreement and kappa (95% CI) coefficient for agreement regarding diagnosis were 85.1% and 0.82 (0.69-0.94), respectively. Percent agreement and kappa (95% CI) coefficient regarding the recommended course of management and the need for additional diagnostic testing were 61.7% and 0.43 (0.22-0.63), and 74.5% and 0.49 (0.25-0.74), respectively. The VE resulted in collection of less physical examination information, took longer to complete and was associated with less satisfaction by both patient and examiner. CONCLUSIONS: Video examination of patients with shoulder disorders may present a valid alternative to FTF examination. Nevertheless, the content of the video-based physical examination may need to be modified to facilitate a clearer detection of indications for specific interventions or diagnostic tests.

[THE TREATMENT OF TRAUMATIC SHOULDER INSTABILITY - THE OPEN APPROACH VS. ARTHROSCOPIC APPROACH].

INTRODUCTION: Shoulder dislocation occurs when the head of the humerus disengages from the glenoid bone. About 95% of shoulder dislocations are traumatic, while the other 5% are not trauma-related in a patient with predisposing factors such as generalized ligamentous laxity. Ninety percent of shoulders dislocate anteriorly from direct force on the arm in the "ABER" position (Abduction- External Rotation). Usually, dislocations are accompanied by injuries to the shoulder that may lead to recurrent anterior shoulder instability and in the long-run, osteoarthritis of the shoulder joint. In the case of traumatic shoulder dislocation in the younger population or competitive sport players, accompanied with bone injury on X-ray's (Bony Bankart or Hill-Sachs), surgical treatment is recommended as soon as possible to avoid recurring dislocation and further joint damage. There are several options to treat recurrent shoulder instability, including soft tissue procedures, bone procedures, and a combination of these procedures. Surgery can be performed by an open or arthroscopic approach.

The infraspinatus test may not be used to screen for shoulder external rotator strength deficits among patients with shoulder pathology.

BACKGROUND: The infraspinatus test is often used to determine the presence of shoulder external rotator strength deficits. As the accuracy of this test has not been established adequately, the purpose of this study was to determine the accuracy of the infraspinatus test in detecting shoulder external rotator strength deficits. METHODS: Sixty-two patients with a unilateral shoulder disorder underwent the infraspinatus test followed by instrumented assessment of shoulder external rotator muscle strength. The infraspinatus test was rated positive or negative based on the presence or absence of a strength deficit on the involved compared with the uninvolved shoulder. The instrumented strength assessment was rated positive or negative based on 4 cutoff thresholds for the presence of a strength deficit on the involved side: ≥10%, ≥15%, ≥20%, or ≥30%. The Sensitivity, specificity, positive and negative likelihood ratio of the infraspinatus test was determined based on each cutoff threshold. RESULTS: Sensitivity ranged from 52.5 to 61.1%, specificity ranged from 72.7 to 90.9%, the positive likelihood ratio ranged from 2.24 to 5.77, while the negative likelihood ratio ranged from 0.52 to 0.59. CONCLUSIONS: As considerable external rotator strength deficits may frequently exist among patients with a negative infraspinatus test, this test may not serve a good screening test for external rotator strength deficits. Contrarily, clinicians can be reasonably certain of the presence of an external rotator strength deficit given a positive infraspinatus test.

Video examination via the smartphone: A reliable tool for shoulder function assessment using the constant score.

BACKGROUND: The use of video examinations (VE) may improve patient care by offering them a low-cost and easy access to physicians, save traveling expenses and shorten waiting time. The aim of this study was to validate the use of Smartphones for distant assessment of shoulder function by comparing the Constant scores (CS) of patients obtained by both VE and conventional face-to-face (FTF) examination. METHODS: Fifty-one subjects (age 19-80 years; women:men 18:33) who presented to a shoulder clinic with a variety of complaints were prospectively recruited and underwent FTF and VE in alternating order. CS obtained by the two methods were compared. Four patients were unable to complete the VE due to technical problems or non-compliance. RESULTS: Forty-seven (92%) subjects successfully completed both examinations. The mean difference in CS was -0.53 points (95%CI: -2.6:1.6), with limits of agreement of -7.7:6 points. Agreement of correlation coefficient, accuracy and precision were 0.91 (95%CI: 0.86:0.96), 0.99 (95%CI: 0.92:1.00) and 0.91 (95%CI: 0.86:0.96), respectively. CONCLUSION: VE can obtain a reliable estimate of shoulder function. The mean video CS was only -0.53 points from the mean frontal CS. Individual variations of CS did not exceed a 7-point distance from the "gold standard" estimate.

Trends in Shoulder Arthroplasty in Israel.

BACKGROUND: The number of patients undergoing shoulder arthroplasty is increasing yearly. OBJECTIVES: To evaluate the results of a consecutive series of patients who underwent shoulder replacement for a variety of indications in a single medical center in Israel. METHODS: All shoulder arthroplasties performed in our institution between 2006 and 2015 were retrospectively reviewed. The functional outcomes and satisfaction of 180 shoulder arthroplasties were evaluated for objective and subjective parameters using the American Shoulder and Elbow Surgeons Shoulder Score (ASES), the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, and the Short Form Health Survey (SF-12). RESULTS: The indications for surgery were osteoarthritis (n=35), rotator cuff arthropathy (n=32), fractures (n=99), and other reasons (n=14). The mean follow-up was 52 months. The scores improved markedly among the patients who underwent surgery later in the study period. The mean DASH score before 2012 was 48.8 and improved to 37.2 after 2013. The respective ASES also improved from 54.2 to 68.6. The use of hemiarthroplasty decreased from 85% to 33% as of 2013, while the use of total shoulder arthroplasty increased. CONCLUSIONS: Shoulder arthroplasty represents an effective treatment modality with satisfactory functional outcomes. Our current study demonstrates a shift from hemiarthroplasty to total shoulder arthroplasty, with the number of procedures increasing yearly. Surgeon experience and the expanding volume of operations had a direct positive effect on the functional outcomes of shoulder arthroplasties.

Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions.

PURPOSE: This study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision. METHODS: ORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months. RESULTS: Thirty-eight patients, age 39 ± 12 years, were operated upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75 ± 1.25 cm vs 8.9 ± 2.3 cm, P = 0.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38 ± 29 cm2 vs 48 ± 28 cm2, P = non-significant). CONCLUSION: Vertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.

Biomechanical evaluation of two arthroscopic techniques for biceps tenodesis: triple loop suture versus simple suture.

BACKGROUND: Several techniques and procedures have been described to treat long head of the biceps pathology; however, tenodesis and tenotomy are the 2 most common procedures performed. This study evaluated the initial fixation strength of the biceps tenodesis triple loop suture (TLS) technique and compared it with that of the simple suture technique (SST). METHODS: Twenty fresh frozen cadaveric human shoulders (humeral head and neck with attached biceps tendons) were harvested. The biceps tendon was tenotomized proximally before reattachment to the bicipital groove of the matching humerus using suture anchors. Tenodesis was performed using the SST or the TLS technique. Specimens were tested biomechanically for load to failure, stress, and stiffness. The mechanism of failure was evaluated and compared between the 2 suture techniques. RESULTS: Maximal load to failure was significantly greater using the TLS technique (122.2 ± 26.73 N) than the SST (46.12 ± 14.37 N, P < .001). There was no difference in the mean stiffness (SST: 7.33 ± 4.41 N/mm, TLS: 7.46 N/mm ± 2.67, P = .94). The failure mechanism in all SST samples occurred by suture cutout through the longitudinal fibers of the tendon. In all TLS samples, the failure occurred by suture slippage. CONCLUSION: This study demonstrated superior load to failure of the TLS compared with the SST technique for biceps tenodesis. Furthermore, this study provides the first description of the TLS technique as a possible application in biceps tenodesis. Clinical application of the TLS must be carefully considered, because although it achieved a superior biomechanical profile, experience with this stitch is limited.

Bicycle-Related Shoulder Injuries: Etiology and the Need for Protective Gear.

BACKGROUND: The popularity of bicycle riding for recreation, exercise and transportation has grown enormously in recent years, which has led to an increased incidence of bicycle-related injuries. While these injuries involve mainly the musculoskeletal system, data on shoulder-specific injuries incurred while bike riding are lacking. Classifying these shoulder injuries may provide insight and assistance in the creation and implementation of effective protective gear and measures. OBJECTIVES: To investigate the types and mechanisms of shoulder injuries among cyclists. METHODS: This study retrospectively examined all cyclists who incurred shoulder injuries while riding and were admitted to the emergency department and shoulder clinic between January 2008 and November 2013. The study included 157 subjects with various bicycle-related shoulder injuries treated with either conservative or surgical measures. RESULTS: Eighty-four percent of injuries were caused by a direct blow to the shoulder, 7% by falling on an outstretched hand, 6% were traction injuries, and 3% were due to hyperabduction. Nine different clinical types of injury were observed; the most common injuries were clavicle fractures (32%), followed by acromioclavicular joint dislocations (22%), rotator cuff tears (22%), and humeral fractures (8%). Fifty-one percent of subjects were managed with conservative care and the remaining patients required surgical interventions. CONCLUSIONS: Shoulder injuries incurred while riding a bicycle span the entire spectrum of shoulder injuries and often result in debilitating conditions. Although the use of helmets is increasing, there is currently no effective protective gear or measures to prevent riders from suffering shoulder injuries.

Recurrent Anterior Shoulder Instability Treated Using the Arthroscopic Bankart-Latarjet Technique: Experience of a Peripheral Hospital.

The arthroscopic Bankart-Latarjet procedure is used in the surgical management of anterior shoulder instability. This technique is mainly performed in referral centers due to its high technicity. This study aimed to evaluate surgical outcomes in a peripheral hospital center. This is a retrospective study of patients treated for recurrent anterior shoulder instability. The clinical scores (Walch-Duplay, Rowe, and Western Ontario Shoulder Instability Index (WOSI)) were assessed preoperatively and at 12 months after surgery. The consolidation and the position of the bone block were evaluated at 6 months using a CT scan. Between 2016 and 2020, 40 patients had been operated on (mean age: 28.5 ± 7.9 years). During a mean follow-up of 29.5 ± 11.6 months, we noted only one complication, a case of fracture of the callus of a consolidated bone block. No recurrence of instability was recorded. The Walch-Duplay score increased from 17.8 to 94.6, the Rowe score from 24.9 to 96.8, and the WOSI score decreased from 52.1% to 6.9%. The bone block was consolidated in 35 patients (87.5%), and a flush position with the anterior edge of the glenoid was noted for all patients. At one year, 67.0% of the patients practicing sport had returned to sports. The arthroscopic Bankart-Latarjet technique was a reliable procedure in the hands of an experienced shoulder surgeon, even in a peripheral hospital center.

Less is better than more with resection of periacetabular tumors - A retrospective 16 years study and literature review.

Introduction: Wide resections of periacetabular tumors create a sizeable bony defect that inevitably results in severe loss of function. Reconstruction of such defects usually requires using large metal implants, a feature associated with considerable surgery extension and complications. The aim of this study is to report resection with no reconstruction of the bony defect. In this retrospective study, we reviewed a consecutive series of 16 patients diagnosed with malignant periacetabular tumors and underwent en-bloc resection without reconstructing their remaining bone defect. Methods: Records were reviewed of 16 consecutive patients diagnosed with malignant periacetabular tumors and underwent en-bloc resection without reconstructing their remaining bony defect. Measurements included: the duration of surgery, blood loss, hemoglobin levels and the need for blood transfusions, data on other hospitalization characteristics, and intraoperative and postoperative complications. Results: Sixteen patients with malignant periacetabular bone tumors and extensive bone destruction underwent wide periacetabular tumor resection with a mean follow-up of 75 months and a mean age of 53 years. The average HOOS score was 46 (range: 20 to 76), and the mean MSTS score was 13% (range: 0 to 15). The mean operative time was 4.1 h, and the mean blood loss was 1200 ml. At their most recent follow-up, patients had a mean shortening of their operated extremity of 4.8 cm, and all could ambulate with assisting devices. Conclusion: Wide resection of periacetabular tumors without reconstruction provides acceptable levels of function and was associated with shorter surgical time, less blood loss and fewer postoperative complications compared to resection with reconstruction. Therefore, this approach may be considered a viable surgical option in patients with an extensive malignant periacetabular. Level III: Retrospective study.

[Metal on metal bearing for total hip arthroplasty].

Total hip arthroplasty has led to a breakthrough in the treatment of patients with degenerative joint diseases and provides an appropriate response to the alleviation of pain and to patient mobility. The constant increase in the rate of operations for relatively young patients, as well as older ones, has raised the necessity for enhancing longevity of implants. It is currently assumed that the main reason for implant failure of conventional joints is the biological reaction to polyethylene wear that leads to bone absorption--osteolysis. In order to avoid this, interest has been renewed on alternative bearing surfaces metal-on-metal new implants technology that reduce the volume of wear particles and improve kinematics of those implants. Current technologies include highly cross-linked polyethylene in metal-on-metal and ceramic-on-ceramic surfaces. This paper reviews and discusses the biomechanical principles of metal-on-metal total hip arthroplasties, and the clinical results of this technology.

Early displacement of two part proximal humerus fractures treated with intramedullary proximal humeral nail.

INTRODUCTION: Proximal humerus nails (PHN) are commonly used for the treatment of simple proximal humerus fractures, and have a reported malunion rate of about 10%. The surgeons who used PHN in one medical institution have noticed a high rate of fracture re-displacement in the early post-operative period. This study's aim is to evaluate the rate of secondary displacement and malunion of patients treated for two part proximal humerus fractures with an angle-stable PHN (MultiLoc), and to assess possible risk factors for this secondary displacement. METHODS: A retrospective study comprised of 25 consecutive patients with 2 part surgical neck or metaphysis displaced proximal humerus fracture, treated with PHN between the years 2014-2017. Results assessed included radiographic measures (neck-shaft angle) and clinical data: range of motion (ROM) and functional scores (Constant, DASH, SSV). A univariate regression analysis was used to assess possible risk factors for secondary displacement. RESULTS: Mean age was 66.6 (range 17-93), and mean follow up was 20 months (range 6-40). Mean neck shaft angle (NSA) changed from 139.1° post operatively to 122.6° at last follow up, with 6 patients (24%) having a NSA change larger than 20°. Two patients (8%) ended up with NSA less than 90°, defined as malunion. The deltoid tuberosity index was found to correlate with the degree of displacement (-0.41, p = 0.04). CONCLUSIONS: PHN for simple displaced proximal humerus fractures was associated with fair clinical results but an unacceptable rate secondary displacement. The deltoid tuberosity index was found to correlate with the degree of this secondary displacement.

Correlation between preoperative imaging parameters and postoperative basic kinematics-based functional outcome in patients with tibial plateau fractures.

BACKGROUND: Functional scores and radiographs are often used to assess function and predict development of osteoarthritis in patients with multi-fragmentary tibial plateau fractures (TPFs). Locomotion, which is the primary goal of fracture treatment, is rarely assessed. The objective of this study was to assess functional ability of patients after TPF fixation using spatio-temporal gait analysis (STGA), and to compare STGA variables with self-reported functional scores and preoperative fracture characteristics. METHODS: Preoperative CT scans of 21 patients with complete articular multi-fragmentary TPFs were evaluated for number of fragments, maximum gap between the fragments and maximum articular depression. All patients underwent STGA (velocity, cadence, step length of the affected and the unaffected leg, single-limb support by the affected and the unaffected leg, and double-leg support) and filled the Knee Society Score and the Short Form-12 questionnaires on average 3 years (SD = 1.56, range, 2-5.8) post-injury. FINDINGS: Step length and single-limb support time of the affected leg were shorter compared to the unaffected leg (p = 0.02 and p = 0.007, respectively). Number of fracture fragments correlated with cadence (R = -0.461, p = 0.04) and velocity (R = -0.447, p = 0.04). INTERPRETATION: Given that both higher fracture comminution and deformity on the one hand and the above gait parameter alterations on the other hand are associated with knee osteoarthritis, STGA may be used for routine postoperative evaluation of patients after TPF fixation.

A positive scapular assistance test is equally present in various shoulder disorders but more commonly found among patients with scapular dyskinesis.

OBJECTIVE: Assess the frequency of a positive scapular assistance test (SAT) in different shoulder disorders and establish its association with scapular dyskinesis. DESIGN: Cross-sectional. SETTING: Shoulder clinic. PARTICIPANTS: Seventy-four patients. MAIN OUTCOME MEASURES: The SAT and visual assessment of scapular movement were performed by a physical therapist. An orthopaedic surgeon classified participants into 4 diagnostic categories: rotator cuff disease, superior labrum anterior posterior lesion (SLAP), shoulder instability, and other. RESULTS: Twenty-seven (36.5%) participants presented with a positive SAT. The SAT was positive among 9 of 28 participants (32.1%) with rotator cuff disease, 7 of 23 participants (30.4%) with SLAP lesions, 9 of 21 participants (42.9%) with shoulder instability, and 2 of 2 participants (100.0%) with other pathologies. The frequency of a positive SAT did not differ between the various diagnostic categories (P = 0.64). The SAT was more frequently positive among participants with scapular dyskinesis (48.5% versus 26.8%, P = 0.05). CONCLUSIONS: The SAT is found similarly positive among patients with various common shoulder disorders. Although associated with scapular dyskinesis, the SAT was positive in less than half of those demonstrating scapular dyskinesis suggesting the SAT may help identify patients in whom altered scapular movement is contributing to shoulder pain.

Favorable radiographic outcomes using the expandable proximal femoral nail in the treatment of hip fractures - A randomized controlled trial.

AIM: To compare the functional and radiographic results of dynamic hip screw (DHS) and expandable proximal femoral nail (EPFN) in the treatment of extracapsular hip fractures. METHODS: A randomized controlled trial of sixty hip fracture patients. Outcomes included mortality, residency, independence, mobility, function and radiographic results at a minimum of 1 year. RESULTS: Twenty-nine EPFN patients demonstrated fewer cases of shaft medialization or femoral offset shortening compared to the 31 DHS patients. Mortality, complications and functional outcomes were similar. CONCLUSION: EPFN provides stable fixation of pertrochanteric hip fractures and prevents neck shortening that is commonly observed after DHS fixation.

Arthroscopic fixation with a minimally invasive axillary approach for latissimus dorsi transfer using an endobutton in massive and irreparable postero-superior cuff tears.

Arthroscopically assisted latissimus dorsi transfer is a viable option for treatment of patients in their 50s to 70s, without arthritis of the glenohumeral joint, who suffer from massive rotator cuff tears that are not amendable to primary repair due to fatty changes in the muscle tissue, or that have failed previous repair attempts. This procedure offers immediate and dramatic pain relief and is not as technically demanding as one might think. Understanding and respecting the principles of tendon transfer is a key to the success of this procedure.

Blood loss and complications following carotid endarterectomy in patients treated with clopidogrel.

This study assessed the effect of uninterrupted antiplatelet therapy on perioperative blood loss and complications in patients undergoing carotid endarterectomy. The files of 107 consecutive patients (mean age 69.5 ± 9 years; range 47-88; 78 men) who underwent carotid endarterectomy were reviewed. Twenty-six patients had been treated with clopidogrel (16 of whom were on combined clopidogrel and aspirin treatment) and compared with non-clopidogrel patients. Antiplatelet treatment was continued until the day of surgery without interruption. Perioperative blood loss and complications were studied. The mean hemoglobin decrease was 1.64 ± 1.2 mg/dL and was not significantly affected by clopidogrel. Surgical time was significantly longer among patients treated with clopidogrel (205 ± 52 minutes on combined treatment and 201 ± 68 minutes on clopidogrel alone versus 165 ± 33 minutes, P < 0.0001). Postoperative complications were similar for all groups and included five strokes, five neck hematomas, one nerve injury and one wound infection. In conclusion, patients treated with clopidogrel before carotid endarterectomy can be expected to have prolonged surgical time. Large cohorts are required to determine whether these patients have more complications.