Management of irreparable subscapularis tears: Current concepts.

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

Covariations between scapular shape and bone density in B-glenoids: A statistical shape and density modeling-approach.

B-type glenoids are characterized by posterior humeral head migration and/or bony-erosion-induced glenoid retroversion. Patients with this type of osteoarthritic glenoids are known to be at increased risk of glenoid component loosening after anatomic total shoulder arthroplasty (aTSA). One of the main challenges in B glenoid surgical planning is to find a balance between correcting the bony shape and maintaining the quality of the bone support. This study aims to systematically quantify variabilities in terms of scapular morphology and bone mineral density in patients with B glenoids and to identify patterns of covariation between these two features. Using computed tomography scan images of 62 patients, three-dimensional scapular surface models were constructed. Rigid and nonrigid surface registration of the scapular surfaces, followed by volumetric registration and material mapping, enabled us to develop statistical shape model (SSM) and statistical density model (SDM). Partial least square correlation (PLSC) was used to identify patterns of covariation. The developed SSM and SDM represented 85.9% and 56.6% of variabilities in terms of scapular morphology and bone density, respectively. PLSC identified four modes of covariation, explaining 66.0% of the correlation between these two variations. Covariation of posterior-inferior glenoid erosion with posterior sclerotic bone formation in association with reduction of bone density in the anterior and central part of the glenoid was detected as the primary mode of covariation. Identification of these asymmetrical distribution of bone density can inform us about possible reasons behind glenoid component loosening in B glenoids and surgical guidelines in terms of the compromise between bony shape correction and bone support quality.

The role of sonication in the diagnosis of periprosthetic joint infection in total shoulder arthroplasty.

An increased sensitivity of sonication compared to periprosthetic tissue cultures in the diagnosis of periprosthetic joint infection (PJI) of hip and knee arthroplasty has been reported. The goal of this study was to determine if there is also an added value of implant sonication in the diagnosis of PJI in total shoulder arthroplasty (TSA). A retrospective analysis of patients who underwent removal of their TSA combined with sonication of the implant for suspicion of PJI between April 2009 and August 2017 was performed. The diagnosis of PJI was based on the major criteria described by Parvizi. We calculated sensitivity, specificity, predictive values, likelihood ratios and diagnostic accuracy for sonication cultures in comparison with periprosthetic tissue cultures. Data from 41 patients were analysed. Standard synovial fluid cultures combined with intraoperative periprosthetic tissue cultures had a sensitivity of 95%, specificity of 95% and total accuracy of 95%. Sonication cultures had a sensitivity of 91%, specificity of 68% and total accuracy of 80%. Six patients had negative standard cultures but positive sonication cultures. In patients with only one positive standard culture, the pathogen of the sonication culture corresponded to the pathogen of the positive soft tissue culture. We found a possible added value of sonication of TSA in the diagnosis of PJI in conjunction with standard intraoperative cultures. In some patients with suspicion of low-grade TSA infection, sonication could identify a possible causal microorganism despite negative standard cultures.

Quantitative statistical shape model-based analysis of humeral head migration, Part 2: Shoulder osteoarthritis.

We wanted to investigate the quantitative characteristics of humeral head migration (HHM) in shoulder osteoarthritis (OA) and their possible associations with scapular morphology. We quantified CT-scan-based-HHM in 122 patients with a combination of automated 3D scapulohumeral migration (=HHM with respect to the scapula) and glenohumeral migration (=HHM with respect to the glenoid) measurements. We divided OA patients in Group 1 (without HHM), Group 2a (anterior HHM) and Group 2b (posterior HHM). We reconstructed and measured the prearthropathy scapular anatomy with a statistical shape model technique. HHM primarily occurs in the axial plane in shoulder OA. We found "not-perfect" correlation between subluxation distance AP and scapulohumeral migration values (rs = 0.8, p < 0.001). Group 2b patients had a more expressed prearthropathy glenoid retroversion (13° vs. 7°, p < 0.001) and posterior glenoid translation (4 mm vs. 6 mm, p = 0.003) in comparison to Group 1. Binary logistic regression analysis indicated prearthropathy glenoid version as a significant predictor of HHM (χ² = 27, p < 0.001). Multivariate regression analysis showed that the pathologic version could explain 56% of subluxation distance-AP variance and 75% of the scapulohumeral migration variance (all p < 0.001). Herewith, every degree increase in pathologic glenoid retroversion was associated with an increase of 1% subluxation distance-AP, and scapulohumeral migration. The occurrence of posterior HHM is associated with prearthropathy glenoid retroversion and more posterior glenoid translation. The reported regression values of HHM in the function of the pathologic glenoid version could form a basis toward a more patient-specific correction of HHM.

Quantitative SSM-based analysis of humeral head migration in rotator cuff tear arthropathy patients.

Rotator cuff tear arthropathy (RCTA) is characterized by massive rotator cuff tearing combined with humeral head migration (HHM). The aim of this study is to investigate the quantitative characteristics of this migration and its association with glenoid erosions and prearthropathy scapular anatomy. We quantified HHM and prearthropathy scapular anatomy of 64 RCTA patients with statistical shape modeling-based techniques. Glenoid erosion was classified according to Sirveaux et al. A cutoff value for confirming HHM was 5 mm based on a control group of 49 patients. Group 1 (RCTA without HHM) consisted of 21 patients, with a mean subluxation distance (SLD) of 3 mm. Group 2 (RCTA with HHM) consisted of 43 patients, with mean SLD of 9 mm, SLD in the anteroposterior plane of -1 mm (SD ± 4 mm), SLD in the superoinferior plane of 7 mm (SD ± 3 mm), and subluxation angle (SLA) of -5° (SD ± 40°). Analysis with Fisher's exact test showed a clear association between HHM and glenoid erosions (p = 0.002). Multivariate regression analysis of Group 2 showed that prearthropathy lateral acromial angle combined with critical shoulder angle (p = 0.004) explained 21% of the observed variability in SLD. The prearthropathy glenoid version explained 23% of the variability in SLA (p = 0.001). HHM in RCTA patients has a wide variation in both magnitude and direction leading to a distorted glenohumeral relationship in the coronal and axial plane. HHM is highly associated with the occurrence of glenoid erosions. There is a correlation between the prearthropathy scapular anatomy and the magnitude and direction of HHM.

The outcome of hydrodilation in frozen shoulder patients and the relationship with kinesiophobia, depression, and anxiety.

PURPOSE: The aims of this study were to (1) investigate the effect of hydrodilatation in frozen shoulder patients on objective indices of shoulder functionality and subjective outcomes of pain, mobility, kinesiophobia, depression, and anxiety, and (2) progress knowledge about the reciprocal temporal relationship between psychological parameters at baseline and objective and subjective outcomes at 3-month follow-up. METHODS: We evaluated the clinical and psychological status of 72 patients with a frozen shoulder before and after hydrodilatation, using the Constant Murley score, the Visual Analogue score, the Tampa Scale for Kinesiophobia, the Hospital Anxiety and Depression Scale, and the Shoulder Pain And Disability Index. RESULTS: We noted a significant improvement in functionality, pain and disability (p < .001). Depression and anxiety improved significantly (p < .001) between baseline and 3-month follow-up. Prospective analyses demonstrated that psychological factors are more likely to predict outcomes of hydrodilatation than vice versa. CONCLUSION: Hydrodilatation followed by physiotherapy is an excellent way to treat patients with recalcitrant frozen shoulder, resulting in a continuous improvement of ROM and pain. Physiotherapists and physicians should be aware that psychological factors might have an impact on the treatment outcome.

Management of periprosthetic infection after reverse shoulder arthroplasty.

BACKGROUND: Periprosthetic shoulder infection (PSI) remains a devastating complication after reverse shoulder arthroplasty (RSA). Currently, scientific data related to the management of PSI are limited, and the optimal strategy and related clinical outcomes remain unclear. Guidelines from the Infectious Diseases Society of America for the management of periprosthetic joint infection are mainly based on data from patients after hip and knee arthroplasty. The aim of this study was to evaluate whether these guidelines are also valid for patients with PSI after RSA. In addition, the functional outcome according to the surgical intervention was assessed. METHODS: An RSA database was retrospectively reviewed to identify infections after primary and revision RSAs, diagnosed between 2004 and 2018. Data collected included age, sex, indication for RSA, causative pathogen, surgical and antimicrobial treatment, functional outcome, and recurrence. RESULTS: Thirty-six patients with a PSI were identified. Surgical treatment was subdivided into débridement and implant retention (DAIR) (n = 6, 17%); 1-stage revision (n = 1, 3%); 2-stage revision (n = 16, 44%); multiple-stage revision (>2 stages) (n = 7, 19%); definitive spacer implantation (n = 2, 6%); and resection arthroplasty (n = 4, 11%). The most common causative pathogens were Staphylococcus epidermidis (n = 11, 31%) and Cutibacterium acnes (n = 9, 25%). Recurrence was diagnosed in 4 patients (11%), all of whom were initially treated with a DAIR approach. The median follow-up period was 36 months (range, 24-132 months). CONCLUSION: PSI is typically caused by low-virulence pathogens, which often are diagnosed with a delay, resulting in chronic infection at the time of surgery. Our results indicate that treatment of patients with chronic PSI with DAIR has a high recurrence rate. In addition, implant exchange (ie, 1- and 2-stage exchange) does not compromise the functional result as compared with implant retention. Thus, patients with chronic PSI should be treated with implant exchange. Future research should further clarify which surgical strategy (ie, 1-stage vs. 2-stage exchange) has a better outcome overall.

Determination of predisposing scapular anatomy with a statistical shape model-Part II: shoulder osteoarthritis.

HYPOTHESIS AND BACKGROUND: Shoulder osteoarthritis can be divided into different glenoid types (A, B, C, and D) and subtypes. The aim of this study was to investigate if there is an association between the prearthropathy scapular anatomy, shoulder osteoarthritis, and different glenoid types and subtypes. METHODS: Using principal components analysis, a statistical shape model (SSM) of the scapula was constructed from a data set of 110 computed tomographic (CT) scans. These subjects formed the control group. Next, CT scan images of 117 patients with osteoarthritis were classified according to the modified Walch classification. A complete 3-dimensional (3D) scapular bone model was created for every patient, and using the SSM, a reconstruction of their prearthropathy scapular anatomy was performed. Automated 3D measurements were performed in both the patient and control group to obtain glenoid version and inclination, critical shoulder angle (CSA), posterior acromial slope (PAS), lateral acromion angle, scapular offset, and the rotational alignment of the coracoacromial complex. These parameters were compared between controls, patients with osteoarthritis, and glenoid types and subtypes. RESULTS: Mean version and inclination for the control group was 6° retroversion and 8° superior inclination (both SD 4°). The mean CSA, PAS, coracoid-posterior acromion angle, posterior acromion-scapular plane angle, and fulcrum axis ratio were 30° (SD 4°), 64° (SD 8°), 116° (SD 9°), 55° (SD 7°), and 46% (SD 4%), respectively. Patients with osteoarthritis had a significant lower CSA, posterior acromion-scapular plane angle, coracoid-posterior acromion angle, and fulcrum axis ratio (27°, 50°, 111°, and 44%, all P < .001). We found a significant difference between the control group and the respective glenoid types for the following parameters: mean CSA and coracoid-posterior acromion angle for A glenoids (27°, P = .001, and 111°, P = .007); mean version, CSA, PAS, coracoid-posterior acromion angle, posterior acromion-scapular plane angle, and fulcrum axis ratio for B glenoids (11°, 27°, 71°, 111°, 49°, and 43%, all P < .001); and mean version, CSA, and posterior acromion-scapular plane angle for D glenoids (2°, P = .002, 26°, P = .003, and 48°, P = .007). DISCUSSION: There seems to be an association between prearthropathy scapular anatomy and shoulder osteoarthritis. A small lateral extension and less posterior rotation of the acromion is associated with shoulder osteoarthritis and is present in almost all types and subtypes of glenoid morphology. Furthermore, B and D glenoids are associated with, respectively, a more and less pronounced prearthropathy glenoid retroversion.

Determination of pre-arthropathy scapular anatomy with a statistical shape model: part I-rotator cuff tear arthropathy.

HYPOTHESIS AND BACKGROUND: Rotator cuff tear arthropathy (RCTA) is a pathology characterized by a massive rotator cuff tear combined with acromiohumeral and/or glenohumeral arthritis. The severity of RCTA can be staged according to the Hamada classification. Why RCTA develops in some patients is unknown. Furthermore, in RCTA patients, distinctly different articular damage patterns can develop on the glenoid side as categorized by the Sirveaux classification (glenoid erosion). The goal of this study was to determine whether an association exists between scapular anatomy and RCTA and different severity stages of RCTA, as well as the associated glenoid erosion types. METHODS: A statistical shape model of the scapula was constructed from a data set of 110 computed tomography scans using principal component analysis. Sixty-six patients with degenerative rotator cuff pathology formed the control group. The computed tomography scan images of 89 patients with RCTA were included and grouped according to the Hamada and Sirveaux classifications. A complete 3-dimensional scapular bone model was created, and statistical shape model reconstruction was performed. Next, automated 3-dimensional measurements of glenoid version and inclination, scapular offset, the critical shoulder angle (CSA), the posterior acromial slope (PAS), and the lateral acromial angle (LAA) were performed. All measurements were then compared between controls and RCTA patients. RESULTS: The control group had a median of 7° of retroversion (variance, 16°), 8° of superior inclination (variance, 19°), and 106 mm of scapular offset (variance, 58 mm). The median CSA, PAS, and LAA were 30° (variance, 14°), 65° (variance, 60°), and 90° (variance, 17°), respectively. In terms of inclination, version, scapular offset, and the PAS, we found no statistically significant differences between the RCTA and control groups. For RCTA patients, the median CSA and median LAA were 32° (P ≤ .01) and 86° (P ≤ .01), respectively. For all investigated parameters, we did not find any significant difference between the different stages of RCTA. Patients with type E3 erosion had a different pre-arthropathy anatomy with increased retroversion (12°, P = .006), an increased CSA (40°, P ≤ .001), and a reduced LAA (79°, P ≤ .001). DISCUSSION: Our results seem to indicate that a 4° more inferiorly tilted and 2° more laterally extended acromion is associated with RCTA. RCTA patients in whom type E3 erosion develops have a distinct pre-arthropathy scapular anatomy with a more laterally extended and more inferiorly tilted acromion and a more retroverted glenoid in comparison with RCTA patients with no erosion. The pre-arthropathy scapular anatomy does not seem to differ between patients with different stages of RCTA.

How much bone support does an anatomic glenoid component need?

BACKGROUND: An important reason for failure of anatomic total shoulder arthroplasty is glenoid component loosening. We investigated the effect of backside bone support on the risk of failure of a glenoid component. METHODS: A finite element model was developed. Virtual surgery was performed for 2 types of glenoid components (cemented all polyethylene [PE] vs. metal backed [MB]), both with gradually decreasing backside bone support. Both bone failure and fixation failure were analyzed. The percentages of bone failure and fixation failure in terms of the critical cement volume (CCV) and micromotion-threshold percentage ratio (MTPR) for the PE and MB components, respectively, were defined and compared. RESULTS: For the reference PE model, the percentages of bone failure and fixation failure (CCV) were 17% and 34%, respectively. With eccentric loading for the MB component, the percentages of bone failure and fixation failure (MTPR) were 6% and 3%, respectively. A global increase in failure was observed with decreasing bone support. The increase in fixation failure, starting from the reference values (MTPR vs. CCV), was relatively more pronounced for the MB component (136% vs. 128%). DISCUSSION: Decreasing backside bone support for an anatomic glenoid component leads to an increased risk of fixation and bone failure. For PE components, decreasing backside support to 95% bone support had only a limited effect. In the case of an MB component, we noticed an increase in micromotion and bone failure already starting from 97% bone support. We conclude that an anatomic glenoid component should always be implanted while maximizing backside bone support.

Automated quantification of glenoid bone defects using 3-dimensional measurements.

BACKGROUND: Assessment of glenoid bone defects is important to select the optimal glenoid component design during shoulder arthroplasty planning and implantation. This study presents a fully automated method to describe glenoid bone loss using 3-dimensional measurements without the need for a healthy contralateral reference scapula. METHODS: The native shape of the glenoid is reconstructed by fitting a statistical shape model (SSM) of the scapula. The total vault loss percentage, local vault loss percentages, defect depth, defect area percentage, and subluxation distance and region are computed based on a comparison of the reconstructed and eroded glenoids. The method is evaluated by comparing its results with a contralateral bone-based reconstruction approach in a data set of 34 scapula and humerus pairs with unilateral glenoid bone defects. RESULTS: The SSM-based defect measurements deviated from the contralateral bone-based measurements with mean absolute differences of 5.5% in the total vault loss percentage, 4.5% to 8.0% in the local vault loss percentages, 1.9 mm in the defect depth, 14.8% in the defect area percentage, and 1.6 mm in the subluxation distance. The SSM-based method was statistically equivalent to the contralateral bone-based method for all parameters except the defect area percentage. CONCLUSION: The presented method is able to automatically analyze glenoid bone defects using 3-dimensional measurements without the need for a healthy contralateral bone.

Treatment of severe glenoid deficiencies in reverse shoulder arthroplasty: the Glenius Glenoid Reconstruction System experience.

BACKGROUND: The treatment of glenoid bone deficiencies in primary or revision total shoulder arthroplasty is challenging. This retrospective study evaluated the short-term clinical and radiologic results of a new custom-made patient-specific glenoid implant. METHODS: We treated 10 patients with severe glenoid deficiencies with the Glenius Glenoid Reconstruction System (Materialise NV, Leuven, Belgium). Outcome data included a patient-derived Constant-Murley score, a visual analog score (VAS), a satisfaction score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Simple Shoulder Test. We compared the postoperative position of the implant with the preoperative planned position on computed tomography scans. RESULTS: At an average follow-up period of 30.5 months, the mean patient-derived Constant-Murley score was 41.3 ± 17.5 points (range, 18-76 points) with a visual analog scale of 3.3 ± 2.5 points (range, 0-7 points). The mean 11-item version of the Disabilities of the Arm, Shoulder and Hand score was 35.8 ± 18.4 (range, 2-71), and the mean Simple Shoulder Test was 47.5% ± 25.3% (range, 8%-92%). Eight patients reported the result as better (n = 3) or much better (n = 5). One patient had an elongation of the brachial plexus, and 1 patient had a period of instability. The average preoperative glenoid defect size was 9 ± 4 cm3 (range, 1-14 cm3). The mean deviation between the preoperative planned and the postoperative version and inclination was 6° ± 4° (range 1°-16°) and 4° ± 4° (range 0°-11°), respectively. CONCLUSION: Early results of the Glenius Glenoid Reconstruction System are encouraging. Adequate pain relief, a reasonable functionality, and good patient satisfaction can be obtained in these difficult cases. Further follow-up will determine the bony ingrowth and subsequent longevity of this patient-specific glenoid component.

Can the contralateral scapula be used as a reliable template to reconstruct the eroded scapula during shoulder arthroplasty?

HYPOTHESIS: The contralateral scapula can be used as a reliable template to determine scapular offset, glenoid inclination, and version of the native scapula in view of reconstructing pathologic scapulae. METHODS: Three-dimensional measurements of scapular offset, inclination, and version were performed using data from a set of 50 bilateral computed tomography scans of full scapulae to determine direct side-to-side differences. RESULTS: The scapula pairs had a mean bilateral difference of 2 mm in offset, 2° in inclination, and 2° in version. Ninety percent of the scapula pairs showed an offset difference smaller than 3 mm. In 96% and 94% of the scapula pairs, the inclination difference and version difference, respectively, were smaller than 5°. The maximum bilateral difference for offset, inclination, and version was 6 mm, 6°, and 8°, respectively. DISCUSSION AND CONCLUSION: The anatomic parameters of scapular offset, glenoid inclination, and version are quite symmetrical and fall into the currently technically feasible accuracy of shoulder arthroplasty implantation. The healthy scapula can be used as a template to guide the reconstruction of the glenoid during shoulder arthroplasty planning in the case of unilateral advanced arthropathy.

Rotator cuff healing after needling of a calcific deposit using platelet-rich plasma augmentation: a randomized, prospective clinical trial.

BACKGROUND: Arthroscopic needling of a rotator cuff calcification is a highly reliable operation in terms of pain relief and return of function. However, during the needling process, a cuff defect is created. Little is known about the evolution of this defect. METHODS: We conducted a prospective, randomized controlled clinical trial to investigate the evolution of the aforementioned defect and the role of platelet-rich plasma (PRP) augmentation in this healing process. Patients were randomized to either group 1 (PRP, n = 20) or group 2 (no PRP [control group], n = 20). Patients in group 1 received a perioperative PRP infiltration at the rotator cuff defect, whereas the control group did not. Patients were assessed clinically preoperatively and postoperatively at 6 weeks, 3 and 6 months, and 1 year. The Constant score, Simple Shoulder Test, and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) were used as outcome measures. The evolution of the cuff defect was evaluated on sonography at 3 and 6 months and with magnetic resonance imaging after 1 year. RESULTS: All patients improved significantly after surgery (P < .05). There was no difference in clinical outcome or rotator cuff healing between groups. We observed a high rate of persistent rotator cuff defects after 1 year in both groups. The presence of residual cuff defects did not influence the clinical outcome. CONCLUSION: Arthroscopic needling is an operation with a predictive, good clinical outcome. We found a high rate of persistent rotator cuff defects after 1 year. This study could not identify any beneficial effect of the addition of PRP on rotator cuff healing. LEVEL OF EVIDENCE: Level II; Randomized Controlled Trial; Treatment Study.

Arthroscopic Removal of Rotator Cuff Calcifications: Operative Technique.

INTRODUCTION: In this article, we present our operative technique for the removal of rotator cuff calcifications. STEP 1 SETUP AND PATIENT POSITIONING: Perform the shoulder arthroscopy with the patient in the beach-chair position with a shoulder positioner. STEP 2 GLENOHUMERAL INSPECTION: Perform an arthroscopic inspection of the glenohumeral joint to exclude concomitant lesions. STEP 3 SUBACROMIAL INSPECTION AND IDENTIFICATION OF SUBACROMIAL LANDMARKS: Ensure that subacromial placement of the arthroscope and identification of the subacromial landmarks are correct as they are necessary for localization of the rotator cuff calcification. STEP 4 IDENTIFICATION AND REMOVAL OF ROTATOR CUFF CALCIFICATION: With a spinal needle, localize and needle the rotator cuff calcification. RESULTS: In our series, all patients undergoing arthroscopic calcification removal exhibited significant improvement in the Constant score (p = 0.003), Quick DASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) (p < 0.001), and Simple Shoulder Test (p < 0.001) at 1 year after the operation8.

Carpal malalignment in malunion of the distal radius and the effect of corrective osteotomy.

Introduction Malunions of the distal radius often induce carpal malalignment. Two different types can be distinguished: an adaptive midcarpal malalignment (so-called CIA wrist: carpal instability, adaptive) and a radiocarpal malalignment (dorsal translation of the whole carpus). The effect of distal radial osteotomy on the carpal alignment has hardly been studied. Material and Methods 31 wrists in 31 patients (mean age 44 years) with malunion of the distal radius after a Colles fracture were treated with a corrective osteotomy. The patients were divided on basis of effective radio-lunate flexion (ERLF) in the two patterns of carpal malalignment. The radiographic changes were evaluated. Results There were 20 patients with midcarpal malalignment (ERLF ≤ 25°) and 11 with radiocarpal malalignment (ERLF > 25°). There was a correction of radial tilt and ulnar variance in both groups. There was a significant improvement of the carpal alignment in the midcarpal malalignment group, up to normal parameters. Neither age nor delay between fracture and osteotomy correlated. In the radiocarpal malalignment group a significant effect on the ERLF was observed. In the patients with dorsal plating 70% of the hardware had to be removed. Conclusion Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and carpal malalignment.

Chronic anterior shoulder dislocation: aspects of current management and potential complications.

Chronic unreduced anterior dislocations of the shoulder are rare. Arterial and neurological complications in chronic glenohumeral dislocations are even less frequent. We report three cases of old anterior shoulder dislocations. Open reduction is indicated for most chronic shoulder dislocations. Arterial lesions require urgent intervention with reconstruction. Conservative treatment is advised for most neurological complications.

Corrective osteotomy of the distal radius: dorsal or volar approach, closing or opening wedge.

The radiological outcomes of 31 corrective osteotomies for malunion of the distal radius were assessed. The procedure re-established normal anatomy in the majority of cases. There was no significant difference in outcome between the dorsal and the palmar approach, but more secondary procedures for hardware removal were necessary with the dorsal approach.

Evaluation of corrective osteotomy of the malunited distal radius on midcarpal and radiocarpal malalignment.

PURPOSE: To quantify 2 patterns of carpal malalignment, midcarpal malalignment (type 1) and radiocarpal malalignment (type 2), and to evaluate the effect of distal radius osteotomy on these malalignment patterns. METHODS: In a retrospective review, we studied 31 wrists treated with corrective osteotomy for distal radius malunion after Colles' fracture, in 31 patients (mean age, 44 y). The patients were divided on the basis of effective radiolunate flexion (ERLF) into 2 patterns of carpal malalignment as measured on preoperative radiographs. There were 20 patients with midcarpal malalignment (ERLF < or = 25 degrees ) and 11 with radiocarpal malalignment (ERLF > 25 degrees ). Measurements of alignment were repeated after distal radius osteotomy and compared with preoperative values. RESULTS: Both groups had correction of radial tilt and ulnar variance with distal radius osteotomy. In the midcarpal malalignment group, carpal alignment improved to normal parameters. In the radiocarpal malalignment group, we observed a notable effect on the ERLF. Neither age of the subject nor delay between fracture and osteotomy correlated with improvement in carpal alignment. CONCLUSIONS: Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and both radiocarpal and midcarpal malalignment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Are clinical photographs appropriate to determine the maximal range of motion of the knee?

Goniometry is a commonly used method for the clinical assessment of range of motion (ROM) of the knee. A digital photograph of the knee in maximal flexion and extension could provide a more objective way to assess the ROM. The aim of our study was to investigate the reliability of the use of digital photographs as a method for measuring the ROM of the knee. Four observers examined 49 patients. Digital photographs of the knee in maximal flexion and extension were compared with standard clinical goniometric measurements in the same position. We observed higher intra-observer reliability for the digital method in flexion (p < 0.0001) and extension (p = 0.005) compared to goniometry. The extension results were numerically lower when using goniometry compared to the digital method (p < 0.001). For both methods, the intra-observer reliability for extension was lower compared to flexion. The intraobserver standard error of measurement (SEM) of the digital method was smaller than the goniometric SEM; the digital method thus appeared more reliable. Measuring maximal flexion and extension on digital photographs is more reliable for both extension and flexion compared to standard goniometric measurements.