Internal Rotation Limitation is Prevalent Following Modern Reverse Shoulder Arthroplasty and Negatively Affects Patients' Subjective Rating of the Procedure.

BACKGROUND: While forward elevation, abduction, and external rotation are often successfully restored, internal rotation (IR) is frequently not satisfactorily recovered following reverse shoulder arthroplasty (RSA), affecting patients' ability to perform certain daily activities. This study examined the prevalence of limited IR in patients receiving modern RSA and its impact on clinical outcomes and patient satisfaction with their RSA. METHODS: A cross-sectional study was conducted on patients who had undergone primary RSA using a modern RSA prosthesis with a minimum one-year follow-up. Patients returned for a research visit where they were examined for range of motion and surveyed for patient-reported outcome measures (PROMs) and subjective rating of the success level of their RSA. Postoperative range of motion data were compared with the preoperative data. The relationship of postoperative IR with PROMs and patients' subjective rating of RSA was analyzed. Logistic regression was performed to identify factors affecting patients' subjective rating of RSA. RESULTS: A total of 78 patients met the criteria and completed the study. A significant portion (59%) reported subjective IR limitations, and 41% showed objective IR limitations. Comparison of preoperative and postoperative IR showed that 24% had worsened IR, while 33% improved. Limited IR was associated with lower patients' subjective rating of RSA and negatively impacted PROMs, especially when the dominant side was operated on. Regression analysis showed that limited IR was the only independent determining factor that was significantly associated with lower subjective rating of RSA. DISCUSSION: Despite advancements in RSA design, limited IR remains a prevalent issue, significantly affecting patients' satisfaction and clinical outcomes. This study underscores the need for setting appropriate expectations regarding IR through patient education and focused efforts to improve IR limitations in RSA patients, particularly on the dominant side.

Effect of making skin incision with electrocautery on positive Cutibacterium acnes culture rates in shoulder arthroplasty: a prospective randomized clinical trial.

BACKGROUND: Cutibacterium acnes remains the most commonly detected organism in shoulder arthroplasty. C acnes infection is thought to occur during shoulder arthroplasty through contamination of the surgical field with C acnes from the incised dermis. The purpose of this study was to examine whether using electrocautery for making skin incisions would decrease C acnes culture rates at the incised dermis compared to using scalpels during shoulder arthroplasty. METHODS: Patients undergoing primary shoulder arthroplasty were randomized into 2 groups, electrocautery vs. scalpel incision group. All patients received a standard preoperative antiseptic preparation including chlorhexidine gluconate showers, intravenous antibiotic administration, and topical application of hydrogen peroxide, povidone iodine, isopropyl alcohol, and DuraPrep. Cultures were obtained from the incised dermal edge immediately after skin incision and later from surgeon's gloves and forceps immediately prior to humeral component implantation. The primary outcome was positive C acnes culture rates compared between the groups. RESULTS: A total of 64 patients (32 in each group) were enrolled. There were 24 males in each group. Regarding dermis cultures, 10 patients (31%) in the scalpel group were positive with 8 of them positive for C acnes, whereas no patients in the electrocautery group were positive (P < .001). Regarding glove cultures, the electrocautery group had 8 patients positive C acnes, while the scalpel group had 8 (P = .777). Regarding forceps cultures, the electrocautery group had 4 patients positive for C acnes, and the scalpel group had 6 (P = .491). All positive cultures were exclusively from male patients. There were no wound complications or infection in the electrocautery group while the scalpel group had 1 acute postoperative infection. CONCLUSIONS: Making skin incisions using electrocautery resulted in 0 C acnes culture at the incised dermis, suggesting its potential effect against C acnes. However, despite this initial antibacterial effect, C acnes still appeared on surgeon's gloves and forceps during surgery of male patients. All positive cultures were from male patients, suggesting that the source of C acnes was specifically related to the male body. While the study hypothesis was supported by the results, the present study also raises new questions and calls for further research.

Open and Arthroscopic Elbow Contracture Release: Tips and Pearls.

Elbow stiffness is a common consequence of trauma and can significantly limit the functionality of the affected arm. Intervention may be necessary for those with a motion arc less than 100°, but the decision to intervene should be based on individual patient needs. Restoration of joint motion in a stiff elbow can be challenging, time consuming, and costly. Nonsurgical treatment is the primary management option, and surgical intervention is considered for refractory stiffness. However, recurrent stiffness is a common issue following surgical elbow contracture release. An overview of relevant elbow anatomy, principles and technical pearls of arthroscopic and open contracture release, and postoperative rehabilitation methods to reduce the risk of recurrent stiffness is provided. It is important to tailor the treatment plan to each patient's unique needs and functional expectations.

Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty: A Prospective Randomized Clinical Trial.

BACKGROUND: While providing effective analgesia following shoulder arthroplasty, an interscalene block has known complications. Local infiltration analgesia (LIA) using ropivacaine has been successfully employed in other joint arthroplasties, but its efficacy in shoulder arthroplasty has not been studied extensively. The purpose of this study was to compare pain and opioid consumption between LIA and an interscalene block following shoulder arthroplasty. METHODS: Patients undergoing primary shoulder arthroplasty were prospectively randomized into 2 groups: the block group received an interscalene block using liposomal bupivacaine, and the injection group received an LIA injection intraoperatively. The LIA injection included ropivacaine, epinephrine, ketorolac, and normal saline solution. Postoperative visual analog scale pain scores, opioid consumption in morphine milligram equivalents, and complications were compared between the groups. The mean pain scores during the first 24 hours postoperatively were used to test noninferiority of LIA compared with an interscalene block. RESULTS: The study included 74 patients (52 men and 22 women with a mean age of 69 years; 37 were in the injection group and 37 in the block group). There was no significant difference between the groups with respect to pain scores at any postoperative time points (p > 0.05), except for the 8-hour time point, when the injection group had a significantly higher pain score than the block group (p = 0.01). There was no significant difference in opioid consumption between the groups at any time points postoperatively (p > 0.05). The amount of intraoperative opioid consumption was significantly higher in the injection group (p < 0.001). In noninferiority testing for the mean pain scores during the first 24 hours, the injection group was found to be noninferior to the block group. One patient in the block group developed transient phrenic nerve palsy. One patient in the injection group developed dislocation after reverse arthroplasty related to noncompliance. The mean procedure hospital charge was $1,718 for an interscalene block and $157 for LIA. CONCLUSIONS: LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. LIA was associated with worse pain at 8 hours postoperatively and more intraoperative opioid consumption but was also substantially less costly. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Optimal Prosthesis Sizing for Radial Head Arthroplasty: A Review of Current Evidence and Guidelines.

¼: Radial head arthroplasty is a viable surgical option when a radial head fracture cannot be reconstructed. Radial head arthroplasty provides a load-bearing articular structure against the capitellum in unstable fractured elbows. ¼: Studies have emphasized the importance of choosing the correct implant size to replicate the native radial head anatomy, citing various consequences of improperly sized radial head prostheses. Overstuffing of the radiocapitellar joint, or lengthening of the radius, has been extensively studied because of its detrimental effects on elbow biomechanics, but other types of improper sizing also have negative consequences. ¼: In the setting of severe fracture-dislocation or revision surgery, anatomic landmarks that are useful for prosthesis sizing often are missing. Various methods have been described to provide guidance for the accurate sizing of a prosthetic radial head; a retrieved radial head, the proximal edge of the lesser sigmoid notch, the radiocapitellar synovial fold, and the ulnohumeral joint space all represent useful references. ¼: Intraoperative radiographic examination is an important step while assessing implant size, including the height of the prosthetic radial head. ¼: Since no single method is perfect on its own, the surgeon should combine as many reference measures as possible, both before and during the procedure, for accurate prosthesis sizing in order to achieve successful outcomes.

Interdepartmental imaging protocol for clinically based three-dimensional computed tomography can provide accurate measurement of glenoid version.

BACKGROUND: Conventional computed tomography (CT) is not accurate for glenoid version measurement. This study sought to examine the feasibility of an interdepartmental protocol implemented between orthopedic surgery and radiology departments for acquisition of anatomic axial CT images and to validate the glenoid version measured through such a protocol. MATERIALS AND METHODS: Data of 30 conventional CT scans of 10 normal and 20 osteoarthritic glenoids were transferred to clinical 3-dimensional imaging software by a radiology technician trained for the study. The technician independently reoriented the scapulae to generate anatomic CT images. A separate team of orthopedic researchers used laboratory-based 3-dimensional reconstruction software (Mimics; Materialise, Leuven, Belgium) to generate anatomic axial images. Three independent examiners measured glenoid version on the conventional CT, reoriented anatomic CT, and Mimics images at the superior, middle, and inferior levels. Data were analyzed using the Mimics data as the "gold standard." RESULTS: Reoriented anatomic CT images generated by the technician resulted in almost identical version measurements to the Mimics images in both normal and arthritic glenoids. The conventional CT images had poor agreement with the Mimics images in normal glenoids but had good agreement in arthritic glenoids. Both normal and arthritic glenoids had increased retroversion superiorly (P < .05), and this phenomenon was significantly exaggerated on the conventional CT images (P < .05). CONCLUSIONS: This study demonstrated that an interdepartmental protocol can produce reoriented anatomic axial CT images on which true glenoid version can be accurately measured. Such an institutional protocol would help surgeons accurately evaluate glenoid version preoperatively with reduced workload and expense.

Role of transplanted bone marrow cells in development of rotator cuff muscle fatty degeneration in mice.

BACKGROUND: Rotator cuff muscle fatty degeneration after a chronic tendon tear is an irreversible pathologic change associated with poor clinical outcomes of tendon repair, and its exact pathogenesis remains unknown. We sought to investigate the role of transplanted bone marrow cells in the development of fatty degeneration, specifically in adipocyte accumulation, using a mouse model. METHODS: Fourteen mice were divided into 2 bone marrow chimeric animal groups: bone marrow transplantation (BMT) group and reverse BMT group. For the BMT group, C57BL/6J wild-type mice underwent whole body irradiation followed by BMT into the retro-orbital sinus from green fluorescent protein (GFP)-transgenic donor mice. For the reverse BMT group, GFP-transgenic mice received BMT from C57BL/6J wild-type donor mice after irradiation. The supraspinatus tendon, infraspinatus tendon, and suprascapular nerve were surgically transected 3 weeks after transplantation. The rotator cuff muscles were harvested 13 weeks after transplantation for histologic analysis and GFP immunohistochemistry. RESULTS: On histologic examination, both groups showed substantial fatty degeneration, fibrosis, and atrophy of the cuff muscles. The BMT group showed no noticeable GFP immunostaining, whereas the reverse BMT group showed significantly stronger GFP staining in most adipocytes (P < .001). However, both groups also showed that a small number of adipocytes originated from transplanted bone marrow cells. A small number of myocytes showed a large cytoplasmic lipid vacuole resembling adipocytes. CONCLUSIONS: This study's findings suggest that most adipocytes in fatty degeneration of the rotator cuff muscles originate from sources other than bone marrow-derived stem cells, and there may be more than 1 source for the adipocytes.

Effect of ulnar tunnel location on elbow stability in double-strand lateral collateral ligament reconstruction.

BACKGROUND: Double-strand lateral ulnar collateral ligament (LUCL) reconstruction is an effective treatment for posterolateral rotatory instability (PLRI) of the elbow, but anatomic landmarks for ulnar tunnel placement are often difficult to identify intraoperatively, which potentially can result in a nonanatomic LUCL reconstruction. This study investigated the effect of ulnar tunnel location on joint stability in double-strand LUCL reconstruction. METHODS: PLRI was artificially created in 7 cadaveric elbows, and double-strand LUCL reconstruction was performed. Five different ulnar tunnels were made along the length of the ulna. In each specimen, each possible pair of 2 tunnels (10 total) were used for graft passage. Varus and posterolateral joint gapping was measured after joint loading using a 3-dimensional digitizer system and X-ray image intensifier. RESULTS: No significant gapping was observed at the posterolateral ulnohumeral joint regardless of the location of the ulnar tunnels (P > .05). In contrast, the lateral radiocapitellar joint showed statistically significant varus gapping when both ulnar tunnels were placed proximal to the radial head-neck junction (P < .05). DISCUSSION: This findings of study suggest that the location of the ulnar tunnels may not be as critical as that of the humeral tunnel during double-strand LUCL reconstruction and that posterolateral rotatory elbow stability can be achieved reasonably well as long as at least 1 of the 2 ulnar tunnels is located at or distal to the radial head-neck junction level.

Intraoperative fluoroscopic assessment of proper prosthetic radial head height.

BACKGROUND: Selecting a properly sized radial head prosthesis is imperative during radial head replacement. Although there has been much emphasis on avoiding overlengthening of the radius, little has been studied about how to avoid shortening. The purpose of this study was to characterize how a radial head replacement appears on intraoperative fluoroscopy depending on the height of the prosthetic radial head. METHODS: Articular cartilage thickness of the radial head was measured in 9 cadaveric elbows. Radial head replacement was performed in each specimen with 4 different prosthetic head heights: 4 mm and 2 mm shortening, anatomic, and 2 mm overlengthening. Anteroposterior fluoroscopic images were obtained for each head height, and the prosthetic radial head height was measured at 3 forearm positions (supination, neutral, and pronation) using the subchondral bone of the lateral edge of the coronoid at the reference point. RESULTS: The mean cartilage thickness of the radial head was 1.3 ± 0.4 mm. The prosthetic radial head appeared 2.2 ± 0.4 mm more proximal than the subchondral bone of the coronoid lateral edge in anteroposterior radiographs when the articular surface of the prosthesis was completely even with the coronoid articular surface. Unlike the native radial head, a prosthetic radial head showed a significant change of height with different forearm rotation (P < .001). DISCUSSION: This study found that a perfectly anatomic radial head replacement appears overlengthened by approximately 2 mm in intraoperative radiographs. This finding can be useful in guiding the appropriate height of a prosthetic radial head.

Effect of tamoxifen on fatty degeneration and atrophy of rotator cuff muscles in chronic rotator cuff tear: An animal model study.

Fatty degeneration of the rotator cuff muscles is an irreversible change resulting from chronic rotator cuff tear and is associated with poor clinical outcomes following rotator cuff repair. We evaluated the effect of Tamoxifen, a competitive estrogen receptor inhibitor, on fatty degeneration using a mouse model for chronic rotator cuff tear. Sixteen adult mice were divided into two diet groups (Tamoxifen vs. Regular) and subjected to surgical creation of a large rotator cuff tear and suprascapular nerve transection in their left shoulder with the right shoulder serving as a control. The rotator cuff muscles were harvested at 16 weeks and subjected to histology and RT-PCR for adipogenic and myogenic markers. Histology showed substantially decreased atrophy and endomysial inflammation in Tamoxifen group, but no significant differences in the amount of intramuscular adipocytes and lipid droplets compared to the Regular group. With RT-PCR, the operated shoulders showed significant upregulation of myogenin and PPAR-γ, and downregulation of myostatin compared to the nonsurgical shoulder. No significant differences of gene expression were found between the two diet groups. Our study demonstrated that tamoxifen diet leads to decreased muscle atrophy and inflammatory changes following chronic rotator cuff tear, but has no apparent effect on adipogenesis.

Posterior Displacement of Supraspinatus Central Tendon Observed on Magnetic Resonance Imaging: A Useful Preoperative Indicator of Rotator Cuff Tear Characteristics.

PURPOSE: To characterize the orientation of the normal supraspinatus central tendon and describe the displacement patterns of the central tendon in rotator cuff tears using a magnetic resonance imaging (MRI)-based method. METHODS: We performed a retrospective MRI and chart review of 183 patients with a rotator cuff tear (cuff tear group), 52 with a labral tear but no rotator cuff tear (labral tear group), and 74 with a normal shoulder (normal group). The orientation of the supraspinatus central tendon relative to the bicipital groove was evaluated based on axial MRI and was numerically represented by the shortest distance from the lateral extension line of the central tendon to the bicipital groove. Tear size, fatty degeneration, and involvement of the anterior supraspinatus were evaluated to identify the factors associated with orientation changes. RESULTS: The mean distance from the bicipital groove to the central tendon line was 0.7 mm and 1.3 mm in the normal group and labral tear group, respectively. Full-thickness cuff tears involving the anterior supraspinatus showed a significantly greater distance (17.7 mm) than those sparing the anterior supraspinatus (4.9 mm, P = .001). Fatty degeneration of the supraspinatus was significantly correlated with the distance (P = .006). Disruption of the anterior supraspinatus and fatty degeneration of the supraspinatus were independent predictors of posterior displacement. CONCLUSIONS: The supraspinatus central tendon has a constant orientation toward the bicipital groove in normal shoulders, and the central tendon is frequently displaced posteriorly in full-thickness rotator cuff tears involving the anterior leading edge of the supraspinatus. The degree of posterior displacement is proportional to tear size and severity of fatty degeneration of the supraspinatus muscle. A simple and quick assessment of the central tendon orientation on preoperative MRI can be a useful indicator of tear characteristics, potentially providing insight into the intraoperative repair strategy. LEVEL OF EVIDENCE: Level IV, diagnostic case-control study.

Functional outcomes after shoulder resection: the patient's perspective.

BACKGROUND: Resection arthroplasty is a salvage procedure used for the treatment of deep-seated infections after total shoulder arthroplasty, hemiarthroplasty, and reverse total shoulder arthroplasty. Previous studies have reported a 50% to 66% rate of pain relief after resection arthroplasty but with significant functional limitations. Our study aimed to qualify the perspective of the patients on their limitations and satisfaction with resection arthroplasty. METHODS: A retrospective record review of resection arthroplasties performed between September 2003 and December 2012 yielded 14 patients, and 7 completed the survey. The patients completed surveys with the focus on the "patient perspective." Functional scores, including American Shoulder and Elbow Surgeons, Simple Shoulder Test, Disabilities of the Arm, Shoulder, and Hand (DASH), DASH work, and DASH sports, were determined. RESULTS: Pain reduction and functional outcomes were similar to past reports of resection arthroplasty. Five of the 7 patients (71%) reported satisfaction with their resection arthroplasty, and 6 of the 7 patients (86%) would undergo the procedure again if given the choice. Five of the 7 patients (71%) were able to most of activities of daily living. CONCLUSIONS: Patients in our study were generally satisfied with their resection arthroplasty. Resection arthroplasty is a reasonable option for treatment of deep-seated periprosthetic infections or for patients with multiple previous failed procedures for total shoulder arthroplasty, hemiarthroplasty. and reverse shoulder arthroplasty.

Factors affecting satisfaction and shoulder function in patients with a recurrent rotator cuff tear.

BACKGROUND: It is widely accepted that most patients treated with rotator cuff repair do well regardless of the integrity of the repair. The purpose of this cross-sectional study was to reexamine this concept and identify the factors affecting the outcomes of patients with a recurrent tear. METHODS: A cohort of patients who had been treated with rotator cuff repair completed a survey regarding satisfaction with the operatively treated shoulder, physical activity, and shoulder function. Ultrasonography was performed to determine rotator cuff integrity. Patients were divided into three age categories: younger than fifty-five years, fifty-five to sixty-five years, and sixty-six years or older. The relationships of the outcomes to patient age, repair integrity, and other demographic factors were analyzed. RESULTS: Forty-seven (26%) of the 180 enrolled patients had a retear, defined as a full-thickness defect. In each age category, the satisfaction, ASES (American Shoulder and Elbow Surgeons), and SST (Simple Shoulder Test) scores in the retear group were significantly poorer than those in the no-retear group (p < 0.05). Within the retear group, all three scores were significantly better in the oldest age category (p < 0.05); there were no significant differences among the age categories within the no-retear group (p > 0.05). Simple regression analysis showed that younger age, a Workers' Compensation claim, and lower education level were significant predictors of poorer scores in patients with a retear (p < 0.05). Multiple regression analysis of the retear group showed that (1) lower education level and a Workers' Compensation claim were independent predictors of a poorer satisfaction score; (2) lower education level, younger age, and a Workers' Compensation claim were independent predictors of a poorer ASES score; and (3) lower education level was the only independent predictor of a poorer SST score (p < 0.01 for all). CONCLUSIONS: The presence of a retear negatively affected the clinical outcomes following rotator cuff repair. This finding refutes the widely held concept that patients typically do well regardless of the repair integrity following rotator cuff repair. In patients with a retear, nonanatomic factors including younger age, lower education level, and a Workers' Compensation claim were associated with poorer outcomes.

Elbow arthroscopic surgery update for sports medicine conditions.

Elbow arthroscopic surgery can now effectively treat a variety of conditions that affect athletes. Advances in instrumentation, increased surgeon familiarity, and expanded indications have led to significant growth in elbow arthroscopic surgery in the past few decades. While positioning, portal placement, and specific instruments may vary among surgeons, anatomic considerations guide surgical approaches to minimize neurovascular compromise. Arthroscopic procedures vary in difficulty, and surgeons should follow stepwise advancement with experience. Removal of loose bodies, debridement of synovial plicae, and debridement of the extensor carpi radialis brevis for lateral epicondylitis are considered simple procedures for novice elbow arthroscopic surgeons. More advanced procedures include management of osteochondritis dissecans, valgus extension overload in the throwing athlete, and capsular release. With proper technique, a variety of athletic elbow conditions can be treated arthroscopically with predictable results and minimal morbidity.

Glenoid implant orientation and cement failure in total shoulder arthroplasty: a finite element analysis.

BACKGROUND: To minimize glenoid implant loosening in total shoulder arthroplasty (TSA), the ideal surgical procedure achieves correction to neutral version, complete implant-bone contact, and bone stock preservation. These goals, however, are not always achievable, and guidelines to prioritize their impact are not well established. The purpose of this study was to investigate how the degree of glenoid correction affects potential cement failure. METHODS: Eight patient-specific computer models were created for 4 TSA scenarios with different permutations of retroversion correction and implant-bone contact. Two bone models were used: a homogeneous cortical bone model and a heterogeneous cortical-trabecular bone model. A 750-N load was simulated, and cement stress was calculated. The risk of cement mantle fracture was reported as the percentage of cement stress exceeding the material endurance limit. RESULTS: Orienting the glenoid implant in retroversion resulted in the highest risk of cement fracture in a homogeneous bone model (P < .05). In the heterogeneous bone model, complete correction resulted in the highest risk of failure (P = .0028). A positive correlation (ρ = 0.901) was found between the risk of cement failure and amount of exposed trabecular bone. CONCLUSIONS: Incorporating trabecular bone into the model changed the effect of implant orientation on cement failure. As exposed trabecular bone increased, the risk of cement fracture increased. This may be due to shifting the load-bearing support underneath the cement from cortical bone to trabecular bone.

Teres minor muscle and related anatomy.

BACKGROUND: The purpose of this study was to describe the complex anatomy surrounding the teres minor muscle. METHODS: Thirty-one cadaveric human shoulders were dissected. Qualitative fascial and neurovascular anatomy were described. Location of motor nerves to teres minor were measured in reference to local anatomy. RESULTS: Fascial anatomy of the posterior shoulder had 2 distinct and equally common variants, 1 of which demonstrated a stout, inflexible fascial compartment enveloping the teres minor muscle. The other had a continuous fascia enveloping both the infraspinatus and teres minor muscles. In both variants, the primary nerve to teres minor traveled around a fascial sling, becoming sub-fascial at an average of 44 mm (range, 25-68) medial to the teres minor's insertion. The nerve took its most angulated course as it entered the fascial sling. Smaller accessory innervation of teres minor began, on average, 30 mm (range, 15-48) medial to the muscle's lateral insertion. None of the accessory motor nerves coursed deep to the fascial sling nor to the distinct teres minor fascial compartment. CONCLUSION: A stout fascial sling may be the potential site of greatest compression and tethering of the primary motor nerve to teres minor. Additional lateral accessory motor nerves to teres minor remained extra-fascial and took a less angulated path. Half of the shoulders demonstrated a separate teres minor fascial compartment. An improved understanding of the fascial anatomy and innervation pattern of the teres minor muscle may help clinicians who treat patients with symptomatic isolated teres minor muscle atrophy.