Correlation between preoperative clinical examination and intraoperatively found subscapularis tendon tear.

PURPOSE: Analyze the diagnostic value for subscapularis (SSC) tendon tears, their correlation between pain and strength on clinical tests, and compare them with intraoperative arthroscopic findings to prove their diagnostic value. METHODS: 110 consecutive patients undergoing arthroscopic rotator cuff repair were reviewed and allocated to isolated SSC (n = 39) and combined anterosuperior tendon tear (n = 71) groups and analyzed. Preoperative clinical testing included belly press (BPT), bear hug (BHT), lift-off (LOT), palm-up (PUT), and Jobe test (JT). All tests were performed in two categories: pain (in 4 categories: 0, 5, 10, and 15) and strength (from 0 to 5). The tendon tears were intraoperatively reviewed and classified. RESULTS: Mean age was 59 years (SD 10). The sensitivity of the BHT was 88.2% and 74.5% for BPT, while specificity was only 41.9% for BHT and 45% for BPT. Sensitivity of JT was 90.5% and 87.5% for PUT, while specificity was only 41% for JT and 28.2% for PUT. A low positive correlation for an intraoperative SSC lesion and the strength of BPT (Spearman rank correlation - 0.425; p value < 0.0001) and the strength of BHT ( - 0.362; p value = 0.001) could be found. With linear regression analysis estimated by ordinary least squares, a correlation between BPT strength and surgical grade of SSC lesion (- 0.528; 95% CI, - 0.923 to - 0.133; pvalue < 0.01) was found. CONCLUSION: The BHT showed a higher sensitivity for a SSC lesion, while the BPT had a higher correlation between preoperative testing, most notably internal rotation strength, and intraoperative surgical grade of the SSC tendon lesion. LEVEL OF EVIDENCE: Level II, Prospective cohort study for Diagnostic tests.

Acceptable Long-Term Outcomes of Arthroscopic Bone Grafting for Recurrent Posterior Shoulder Instability: Minimum Follow-Up of 5 Years.

PURPOSE: To examine the long-term clinical outcome associated with arthroscopically placed autologous iliac crest bone graft (ICBG) for recurrent posterior shoulder instability. METHODS: From January 2008 to December 2013, patients treated with posterior ICBG and a minimum follow-up of 5 years were included. Clinical outcome of patients operated with a posterior ICBG was analyzed with multiple patient-reported outcome measures included Constant (CS), American Shoulder and Elbow Surgeons (ASES), Walch-Duplay, and Rowe scores, shoulder subjective value, and pain visual analog score. Patient satisfaction was assessed by asking the patients their overall level of satisfaction at last follow-up on a 1 to 10 scale. RESULTS: In total, 18 patients (19 shoulders) were included. At a mean follow-up of 7.3 years (range, 5-10 years), patients had significant improvements in their mean CS from 63 (standard deviation [SD] 18) to 80 (SD 18; P = .005), ASES from 57 (SD 18) to 81 (SD 18; P = .003), Walch-Duplay from 34 (SD 31) to 79 (SD 22; P < .001), and Rowe score from 37 (SD 23) to 79 (SD 24; P < .001). Pain level decreased from 5.6 (SD 2.5) preoperative to 2.3 (SD 2.3; P < .001) and shoulder subjective value improved 58 (SD 20) to 76 (SD 24; P = .002). Global satisfaction with the procedure was 8.4 (SD 2.1). Clinical significance was met or exceeded by 84% for CS and 89% of the patients for ASES and 95% met or exceeded satisfaction threshold for CS. There were 7 shoulders (37%) reoperated for symptomatic screw irritation. CONCLUSIONS: This series reporting on the long-term follow-up after arthroscopic posterior ICBG for recurrent posterior shoulder instability demonstrates, despite a high number of reoperations for symptomatic screw irritation, its effectiveness with acceptable clinical outcomes and satisfied patients. LEVEL OF EVIDENCE: IV, therapeutic case series.

Endoscopic brachial plexus neurolysis in the management of infraclavicular nerve injuries due to glenohumeral dislocation.

INTRODUCTION: Infraclavicular brachial plexus (BP) injury secondary to glenohumeral joint (GHJ) dislocation is a rather common complication, which may be accountable for long-lasting deficits. The purpose of this study was to assess the potential benefits of BP neurolysis in such presentation, using an endoscopic approach. MATERIALS AND METHODS: All patients who underwent endoscopic BP neurolysis in the setting of infraclavicular BP palsy due to GHJ dislocation were included. Preoperative physical examination was conducted to classify the observed motor and sensitive deficits into nerves and/or cord lesions. Six weeks after the trauma, examination was repeated and endoscopic BP neurolysis was elected if no significant improvements were observed. If nerve ruptures and/or severe damages were identified during surgery, nerve reconstructions were conducted within a month; in other cases, follow-up examinations were conducted at 6 weeks, 3 and 6 months to assess the course of postoperative recovery. RESULTS: Eleven patients were included, including 6 men and 5 women, with a mean age of 43 ± 23 years (16;73). Six patients had at least one cord involved, four patients had isolated axillary nerve palsy, and one patient had a complete BP palsy. In 7 patients with cord lesions and/or isolated axillary nerve palsy, at least grade-3 strength, according to the British Medical Research Council grading system, was noted in all affected muscles within 6 weeks following the neurolysis; after 3 months of follow-up, grade-4 strength was observed in all muscles, and all but patients but one had fully recovered within 6 months. In 3 patients with isolated axillary nerve palsy, complete nerve ruptures (n=2) and severe damages (n=1) were identified under scopic magnification; secondary nerve transfers were conducted to reanimate the axillary nerve, and all patients fully recovered within a year. In one patient with complete BP palsy, improvements started after 6 months of follow-up, and full recovery was yielded after 2 years. No intra- and/or postoperative complications were noted. CONCLUSIONS: At the cost of minimal additional morbidity, endoscopic BP neurolysis appears to be a safe and reliable procedure to shorten recovery delays in most patients presenting with BP palsy due to GHJ dislocation.

Distal sensory disorders in Dupuytren's disease.

PURPOSE: Dupuytren's disease is a common and disabling condition. Its pathophysiology is not well understood. Some patients complain of postoperative loss of fingertip sensitivity that could be due either to the surgery or to the disease itself. Our hypothesis is that distal sensory disorders are a component of Dupuytren's disease. METHODS: We performed a prospective, single-center study to compare two populations: controls and patients with Dupuytren's disease. Subjects were excluded if they were under 18 years of age or had any disease or treatment that could alter finger sensitivity or test comprehension. Sensitivity was determined using Weber's static two-point discrimination test. Each ray of the tested hand in the Dupuytren's patients was classified as healthy or diseased; the diseased rays were graded using the Tubiana stages and the type of involvement (pure digital, pure palmar, palmar-digital). RESULTS: The study enrolled 56 patients in two comparable groups of 28 patients and 28 controls. A statistically significant difference was found between the affected hands of Dupuytren's patients and the hands of the controls. There was also a significant difference in the mean sensitivity of affected and normal rays in the Dupuytren's patients. CONCLUSION: Preoperative distal sensory disorders are a component of Dupuytren's disease that could be related to neuropathy and/or mechanical nerve compression. LEVEL OF EVIDENCE: IV, case-control study, diagnostic study.