Benefits of bone graft augmentation to arthroscopic Bankart repair for recurrent anterior shoulder instability with glenoid bone loss.

PURPOSE: Glenoid bone loss contributes to recurrent instability after arthroscopic Bankart repair alone. With significant glenoid bone loss, better results have been reported after arthroscopic Bankart repair with glenoid arc reconstruction. However, no reports compare augmentation using bone graft with non-augmentation for glenoid bone loss. The purpose of this study was to assess clinical results of an arthroscopic Bankart repair with or without arthroscopic bone graft augmentation. It was hypothesized that such bone graft augmentation would restore shoulder stability, and lead to excellent outcomes. METHODS: Of 552 patients treated for anterior glenohumeral instability with arthroscopic Bankart repair, 68 met this study's inclusion criteria of glenoid bone loss over 20% and follow-up of at least 2 years. Patients were divided into 2 groups based on whether with bone graft augmentation for glenoid bone loss [Group A: n = 35, median age; 21 years (range 13-72 years)], or not (Group B: n = 33, median age; 21 years (range 13-50 years)]. For grafting, either autologous iliac bone or artificial bone made of hydroxyapatite was used. Rowe score, recurrence rate, and return to sport were used to assess the results. RESULTS: Mean Rowe score was 95.0 (SD 10.6) in Group A and 69.7 (SD 27.2) in Group B (p < 0.05). The recurrence rate was 2.9% (1/36) in Group A and 48.5% (16/33) in Group B (p < 0.05). Regarding contact/collision athletes, 24 were contained in Group A and 22 in Group B. Of the patients with recurrence in Group B, 13 (59.1%) were contact/collision athletes. Finally, 50% of the contact/collision sports athletes for both groups returned to their sports at the same as pre-injury level. Of the 11 patients who returned to the same level of contact/collision sports in Group B, seven returned with residual instability. Nine athletes in Group A and 3 in Group B quit their sports for personal or social reasons. CONCLUSIONS: Bone graft augmentation was beneficial when used with Arthroscopic Bankart repair for recurrent anterior shoulder instability with glenoid bone loss. Especially, for recurrent anterior shoulder instability with glenoid bone loss in contact/collision sports athletes, bone graft augmentation should be strongly considered as beneficial. LEVEL OF EVIDENCE: Level IV.

Morphological evaluation of the scapula by three-dimensional computed tomography to elucidate shoulder joint function.

INTRODUCTION: There are many variations of scapula morphology. Evaluation of scapula morphology is necessary to elucidate shoulder joint movement. We aimed to analyze the bone morphology of various parts constituting the scapula to identify certain conserved features among them. MATERIALS AND METHODS: Thirty-one healthy individuals were the subjects. We created a scapular three-dimensional (3D) model using computed tomography (CT). X and Y axes were set on a glenoid surface. We measured the approximate plane of the upper and lower scapular bodies and scapular spine and the central axis of the coracoid and acromion. The anatomical position of the scapular spine, upper and lower bodies, coracoid, and acromion was measured. The positional relationship between the upper and lower bodies and scapular spine and the coracoid and acromion was evaluated. The average angle of the upper and lower scapular bodies and the scapular spine with respect to the XZ plane was calculated. The average angle of the coracoid and acromion with the X-axis on the XY plane and Z-axis on the YZ plane was calculated. RESULTS: On the XY plane, approximate planes of the upper and lower part of the body and the scapular spine were significantly correlated to each inclination. On the XY plane, inclinations of the central axes of the coracoid and acromion were significantly correlated. CONCLUSIONS: The findings revealed for the first time the correlation between the inclinations of the scapular body and scapular spine and the inclination angle between the coracoid and acromion.

The outcome of hemiarthroplasty for proximal humeral fractures is dependent on the status of the rotator cuff.

PURPOSE: The purpose of this study was to evaluate clinical and radiological outcomes of hemiarthroplasty for proximal humerus fractures. METHODS: Thirty-five patients (33 women and two men), average age at the time of surgery of 75.1 (range, 64-92) years, who underwent hemiarthroplasty for proximal humerus fracture or fracture-dislocation of the shoulder were enrolled in this study. The Constant score was used for clinical evaluation of outcomes, and X-rays were performed after a minimum follow-up period of 12 months postoperatively. Parameters for radiological evaluation were as follows: value of acromiohumeral interval (AHI), humeral offset, medial and lateral projection, and the existence of subacromial spur, a radiolucent zone around humeral stem and an osteolytic change of the greater tuberosity. RESULTS: The average follow-up after surgery was 45.8 (range, 13-114) months. The average postoperative Constant score was 76.2 (range, 53-96) points. The mean values of AHI and humeral offset were 8.4 and 28.3 mm, respectively. A subacromial spur was observed in ten patients, and an osteolytic change of the greater tuberosity in seven patients. There was a significant correlation between Constant score and values of AHI or humeral offset. The Constant score in patients with a subacromial spur or radiolucent zone around humeral stem was markedly lower than that in patients without them. CONCLUSIONS: The clinical outcome of hemiarthroplasty was influenced by factors reflecting function and conditions of the rotator cuff. Anatomical reconstruction and bone union of the tuberosities need to ensure clinical success in hemiarthroplasty.

Nerve Block for Pain Relief During Arthroscopic Rotator Cuff Repair.

BACKGROUND: Although arthroscopic rotator cuff repair (ARCR) often results in good outcomes, some patients have severe pain postoperatively. This study investigated the efficacy of nerve block for ARCR. METHODS: This study was retrospective, and consent was obtained from all patients. We divided 50 patients who had undergone ARCR into 4 groups: continuous interscalene nerve block was performed for 11 patients (continuous-injection group), single interscalene nerve block for 10 (single-injection group), suprascapular nerve block for 8 (suprascapular group), and intravenous analgesic administration for 10 (intravenous group). Eleven patients received no nerve block (control group). We evaluated diclofenac sodium and pentazocine dosing, visual analog scale (VAS) scores, and perioperative complications in each group. VAS scoring was done immediately after surgery and 1 and 6 hours and 1, 2, 3, 7, and 14 days postoperatively. RESULTS: The doses of diclofenac sodium and pentazocine did not differ between groups. VAS scores immediately after surgery and at 1 and 6 hours after surgery were significantly lower in the single-injection and continuous-injection groups than in the suprascapular, intravenous, and control groups. VAS score at 1 day postoperatively was significantly lower in the continuous-injection group than in the other groups. One patient in the continuous group reported temporary paralysis of the fingers and drug solution leakage. CONCLUSION: Interscalene nerve blocks yielded good pain relief for ARCR. Although continuous interscalene nerve block produced continuous pain relief, complications are a concern.

Tarsal Navicular Stress Fracture in a Young Athlete: A Case Report.

Approximately 30% of tarsal navicular stress fractures are missed by physicians because plain radiographs often show no diagnostic clues. If early diagnosis and treatment are not obtained, such fractures will become refractory and the patient will no longer be able to actively participate as an athlete. We herein describe our experience treating a 14-year-old female track sprinter with persistent foot pain. Magnetic resonance imaging 6 months after the onset of pain showed a stress fracture of the tarsal navicular bone. Computed tomography showed the tarsal navicular stress fracture as well as sclerosis at the fracture edges. We diagnosed a refractory tarsal navicular stress fracture. Conservative management in the form of non-weight-bearing cast immobilization is the standard treatment for both partial and complete stress fractures of the tarsal navicular bone. However, surgical treatment is required in refractory cases. We treated the herein-described refractory case with 6 weeks of non-weight-bearing cast immobilization. We instructed the patient to perform quad muscle training at the same time as casting. Six weeks later, follow-up computed tomography showed callus formation and disappearance of the fracture line. The patient thus began full weight bearing with daily use of arch support equipment, and we allowed her to gradually return to sports. We gradually increased her activity intensity from jogging to running. She completely and successfully returned to sports after 3 months of treatment.

Factors influencing outcomes of nonsurgical treatment for baseball players with SLAP lesion.

BACKGROUND/OBJECTIVE: Superior labrum anterior posterior (SLAP) lesion of the shoulder joint occurs in throwing athletes as a results of overuse, such as from repetitive baseball pitching. Nonsurgical treatments are usually the first-line therapy for symptomatic SLAP lesion. However, some patients cannot obtain satisfactory improvement of their symptoms, leading to dysfunction of the shoulder and diminished pitching performance. The purpose of this study was to analyze factors that influence outcomes of nonsurgical treatments for SLAP lesion. METHODS: Forty-five baseball players with SLAP lesion, whose mean age was 21.6 (range, 16-36) years and who underwent nonsurgical treatments, were the subjects of this study. SLAP lesion was diagnosed by shoulder arthrography and magnetic resonance imaging (MRI). Exclusion criteria included definite associated trauma such as dislocation, fracture or injuries related to sports activities. Playing positions included pitcher (21 patients), catcher (3 patients), infielder (13 patients) and outfielder (8 patients). Mean symptomatic duration from the onset of shoulder pain to the beginning of nonsurgical treatments was 8.5 (range, 1-72) months. Nonsurgical treatments included physical therapy, such as range of motion, stretching, and rotator cuff exercises, as well as prescription of nonsteroidal anti-inflammatory drugs if necessary. To identify factors that influenced outcomes of nonsurgical treatments for SLAP lesion, various factors of 13 nonresponsive patients were compared with those of 32 patients who responded to nonsurgical treatment. The factors were as follows: patient background, such as age or playing position; range of shoulder motion; shoulder joint laxity; and findings of radiographs and MRI. All data were statistically assessed using logistic analysis and Spearman's correlation coefficient. The significance level was set at P < 0.05, and odds ratios were determined. RESULTS: Factors identified as having significant difference between the 2 groups were age, duration of baseball experience, symptomatic period, playing position, range of internal and external rotation in the first medical examination, range of total rotation of 90° abduction 2 months after nonsurgical treatments, and presence of Bennett spur and partial-thickness tears of the articular-side rotator cuff. Factors with high odds ratios were symptomatic period, range of total rotation of 90° abduction 2 months after the treatment, age, and duration of baseball experience. CONCLUSION: Symptomatic period, duration of baseball experience, age, and findings of radiographs and MRI are inevitable factors that cannot be improved by nonsurgical treatment. On the other hand, restriction of shoulder motion due to posterior muscular tightness is a factor that can be improved by nonsurgical treatment. Early improvement of shoulder motion is important to obtain satisfactory outcomes of nonsurgical treatments for SLAP lesion.

Characteristics of the patients with delaminated rotator cuff tear.

PURPOSE: The purpose of this study was to analyze factors relating to delamination in full-thickness rotator cuff tears. METHODS: 126 patients with full-thickness rotator cuff tears treated by arthroscopic rotator cuff repair were the subjects of this study. There were 52 females and 74 males whose average age was 64.2 years. Fifty-three patients had history of trauma. The average duration of disorder was 29.5 weeks. Nineteen patients were diagnosed with diabetes. On types of the tears, small tear was observed in 59 patients, medium tear in 47 patients, large tear in 6 patients, and massive tear in 14 patients. The average size of tear was 1.98 cm. Delamination of the torn cuff was observed in 45 patients. Factors compared between the patients without delamination and those with delamination were as follows: gender and age of the patients, history of trauma, duration of disorder, diabetes, smoking, size and number of rotator cuff tears. RESULTS: The delamination rate of the smoking patients was significantly higher than non-smoking patients. The delamination rate of patients with more than two tendon tears was significantly higher than those with only one tendon tear. The average size of tear with delamination was significantly larger than that of tear without delamination. The other factors were not related to delamination. CONCLUSIONS: This study suggests that smoking, size of tear and number of torn cuffs are associated with delamination. The progression of torn cuff, anatomical features and nicotine of smoking affect the causes of delaminated tear of rotator cuff.

Arthroscopic Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Dislocation.

BACKGROUND: The purpose of this study was to evaluate mid- and long-term clinical and radiologic outcomes of arthroscopic coracoclavicular ligament reconstruction (ACCLR) with an artificial ligament for acute dislocation of the acromioclavicular joint (ACJ). METHODS: Twelve male patients (average age at the time of surgery: 40.8 years, range: 21-64 years) underwent ACCLR with an artificial ligament for acute dislocation of the ACJ type III or type V according to the Rockwood classification. Arthroscopic surgery was performed with the patient under general anesthesia and interscalene brachial plexus block in the beach-chair position. Reduction of the ACJ was performed manually or using an elevator under control of an imaging intensifier. The ACJ was fixed temporarily with a Kirschner wire. Bone tunnels of the coracoid process and clavicle were made with a cannulated drill. An artificial ligament was pulled out through the bone tunnels and fixed on the upper surface of the clavicle with a staple and interference screw, and on the undersurface of the coracoid process with an Endobutton. The shoulder was immobilized with a shoulder brace for 4 weeks postoperatively, and rehabilitation was started in the first postoperative week. The Japan Shoulder Society Acromioclavicular Joint Function Assessment (JSS-ACJ) score was used for evaluation of clinical outcomes, and plain radiographs were performed after a minimum follow-up period of 5 years postoperatively. RESULTS: The average follow-up period after surgery was 106.3 months (range: 62-128 months). The average postoperative JSS-ACJ score was 97.2 points (range: 92-100). The seven patients who had been playing sports before injury all returned to their pre-injury level. No patients complained of pain or shoulder dysfunction in daily activities, work, or sports. There were no complications such as neurovascular injuries during surgery, infection, or foreign body reaction from the artificial ligament. Radiographs at the final follow-up showed subluxation of the ACJ and non-symptomatic osteoarthritic changes of the ACJ in two patients, respectively. CONCLUSION: ACCLR for acute dislocation of the ACJ is a useful surgical procedure that gives satisfactory clinical and radiologic outcomes on mid- and long-term follow-up. ACCLR can stabilize vertical instability of the ACJ. If instability in the horizontal direction remains, repair or reconstruction of the acromioclavicular ligament should be added to prevent osteoarthritic changes of the ACJ.

Clinical outcomes and structural integrity of arthroscopic double-row versus suture-bridge repair for rotator cuff tears.

The purpose of this study was to compare clinical outcomes and retear rate between arthroscopic double row (DR) and suture bridge (SB) repair for rotator cuff tears. Postoperative Constant score and MRI findings were compared between 52 patients underwent DR repair and 63 patients underwent SB repair with medium tear of the supraspinatus. There was no significant difference in Constant score between the two groups. Postoperative MRI revealed that retear rate of SB group was significantly lower than DR group. This study suggests that SB repair can provide better clinical and structural outcomes compared with DR repair.

Arthroscopic Removal and Tendon Repair for Refractory Rotator Cuff Calcific Tendinitis of the Shoulder.

BACKGROUND: The purpose of this study was to evaluate clinical and radiological outcomes of arthroscopic treatment for refractory rotator cuff calcific tendinitis of the shoulder. METHODS: Subjects were 37 patients (35 women and 2 men; mean age, 47.8 years; age range 34-61 years) who had undergone arthroscopic treatment for calcific tendinitis of the shoulder. Despite sufficient nonsurgical treatments, all patients had residual calcific deposit with persistent or recurrent pain. Before surgery, all patients underwent 3-directional radiographs of the shoulder and three-dimensional computed tomography to determine the location and size of calcific deposit. Arthroscopic surgery was performed with the patient under general anesthesia in the lateral decubitus position. A 2-cm single longitudinal incision was made with a radiofrequency hook blade on the tendon surface above calcific deposit. Calcific deposit was removed as much as possible with a curette and a motorized shaver. The incised tendon was repaired with a side-to-side suture with strong sutures. The Japanese Orthopaedic Association shoulder score was used to evaluate clinical outcomes. The extent of calcific deposit removal was evaluated with radiographs obtained before surgery, 1 week after the surgery and at the final follow-up examination. RESULTS: The mean follow-up duration was 30.4 (range, 13-72) months. The mean shoulder score significantly improved from 69.7 (range, 58-80) points before surgery to 97.8 (range, 89-100) points at the final follow-up examination. Postoperative radiographs in all patients, showed that the calcific deposit was resolved or reduced and those from 1 week after surgery to the final examination showed no evidence of recurrence or enlargement of calcific deposit. The calcific deposit had completely resolved in 34 patients but remained in 3 patients. CONCLUSION: When treating calcific tendinitis of the shoulder, it is important to accurately determine the size and location of calcific deposit by radiographs and 3-dimensional computed tomography. Satisfactory clinical and radiological outcomes can be expected after reliable removal of calcific deposit through a single longitudinal incision and side-to-side repair with strong sutures, in association with an appropriate rehabilitation program.

SLAP repair with arthroscopic decompression of spinoglenoid cyst.

INTRODUCTION: A spinoglenoid cyst with suprascapular nerve disorders is highly associated with superior labrum anterior posterior (SLAP) lesion. Conservative or surgical treatment is applied to relieve pain and neurological symptoms. The purpose of this study was to evaluate clinical outcomes of patients treated by arthroscopic surgery for SLAP lesion with a spinoglenoid cyst. METHODS: The subjects of this study were six patients with SLAP lesion with a spinoglenoid cyst who underwent arthroscopic surgery. There was one female and five males with a mean age of 48.5 years. SLAP lesion was found in all the patients at arthroscopy. A small tear of the rotator cuff was found in the two patients. The SLAP lesion was repaired using suture anchors, and the rotator cuff tears were repaired by suture-bridge fixation. The spinoglenoid cyst was decompressed through the torn labrum in three patients, and through the released superior to posterior portion of the capsule in the other three patients. RESULTS: All patients showed excellent improvement in pain and muscle strength at the final follow-up examination. The mean Constant score was improved from 60.5 points preoperatively to 97.2 points postoperatively. The mean visual analog scale (VAS) score decreased from 4.5 on the day of the surgery to 2.5 within one week postoperatively. Postoperative MRI showed disappearance or reduction of the spinoglenoid cyst in four and two patients, respectively. There were no complications from the surgical intervention and in the postoperative period. DISCUSSION: The patients treated by decompression through the released capsule obtained pain relief at an early period after the surgery. Arthroscopic treatment for a spinoglenoid cyst can provide a satisfactory clinical outcome. Arthroscopic decompression of a spinoglenoid cyst through the released capsule is recommended for a safe and reliable procedure for patients with suprascapular nerve disorders.

Stress fracture of the radial styloid process in a judo player: a case report.

Stress fractures of the upper limbs are uncommon, and are most often reported as individual cases or small series. In particularly, stress fractures around the wrist are even less common. A stress fracture of the radial styloid process in a judo player was surgically treated, and a favorable treatment outcome was obtained. A 16-year-old adolescent boy experienced pain in the right wrist, with no apparent trigger, while playing judo. Stress fracture of the radial styloid process was diagnosed with plain radiographs and was treated conservatively with cast immobilization. Although bone union was achieved, the fracture recurred after he resumed paying judo. Thus, surgical treatment was performed. The procedure was resection of the distal bone fragment. He resumed practicing 2 months postoperatively and returned to judo matches after 1 more month. As of 1 year after distal bone fragment resection, he was able to participate in judo without pain, limited range of motion, or instability of the wrist.

Synthesis, structures and stability of amido gold(iii) complexes with 2,2':6',2''-terpyridine.

Three gold(iii) complexes with terminal amido ligands were prepared by the reaction of [Au(III)(trpy)(OH)](ClO4)2 and primary amines having electron-withdrawing groups such as 2-amino-4-chloropyrimidine, 2-amino-5-chloro-pyridine, and 2-aminopyrimidine. Conversion of the amido ligands into the imido or amine ligands resulted in the decomposition of the complexes by intramolecular redox reaction or the release of amine ligands, respectively.