The Fate of the Shoulder Post Rotator Cuff Repair: Biomechanical Properties of the Supraspinatus Tendon and Surrounding Structures.

The study aimed to describe the changes in biomechanical properties of the supraspinatus tendon, deltoid muscle, and humeral head post arthroscopic rotator cuff repair using shear wave elastography. Shear wave velocity of the tendon, deltoid, and humeral head of 48 patients was measured at predetermined sites at 1 week, 6 weeks, 12 weeks, 6 months, and 12 months post repair. One-way ANOVA with Tukey's correction and Spearman's correlation were performed. Mean±SEM healing tendon stiffness, adjacent to tendon footprint, increased from 1 week (6.2±0.2 m/s) to 6 months (7.5±0.3 m/s) and 12 months (7.8±0.3 m/s) (P<0.001). Mean±SEM deltoid muscle stiffness was higher at 12 months (4.1±0.2 m/s) compared to 1 week (3.4±0.1 m/s) and 12 weeks (3.5±0.1 m/s) (P<0.05). Humeral head stiffness did not change. Following arthroscopic rotator cuff repair, supraspinatus tendon stiffness increased in a curvilinear fashion over 6 months. From 6 months, deltoid muscle stiffness increased, corresponding to when patients were instructed to return to normal activities.

Minimally invasive lateral plating for diaphyseal fractures with extension into the proximal humerus and its implications for the deltoid muscle and its distal insertion: functional analysis and MR-imaging.

BACKGROUND: In minimally invasive lateral plate osteosynthesis of the humerus (MILPOH) the plate is introduced through a deltoid split proximally and advanced through the central portion of the deltoid insertion and between bone and brachial muscle to the distal aspect of the humerus. The fracture is then indirectly reduced and bridged by the plate. Whereas it has been shown that the strong anterior and posterior parts of the distal deltoid insertion remain intact with this maneuver, its impact on deltoid muscle strength and muscular morphology remains unclear. It was the aim of this study to evaluate deltoid muscle function and MR-morphology of the deltoid muscle and its distal insertion after MILPOH. METHODS: Six patients (median age 63 years, range 52-69 years, f/m 5/1) who had undergone MILPOH for diaphyseal humeral fractures extending into the proximal metaphysis and head (AO 12B/C(i)) between 08/2017 and 08/2020 were included. Functional testing was performed for the injured and uninjured extremity including strength measurements for 30/60/90° shoulder abduction and flexion at least one year postoperatively. Constant-Murley-Score (CMS) including an age-and gender-adjusted version, were obtained and compared to the uninjured side. Oxford Shoulder Score (OSS) and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire were acquired for the affected extremity. Quality of life was measured using the EQ visual analogue scale (EQ-5D-5 L VAS). MR imaging was performed for both shoulders accordingly at the time of follow-up to assess the integrity of the distal insertion, muscle mass and fatty degeneration of the deltoid muscle. Muscle mass was determined by measuring the area of the deltoid muscle on the axial MR image at the height of the center of the humeral head. RESULTS: Median follow-up was 29 months (range 12-48 months). Median difference of abduction strength after MILPOH was + 13% for 30°, 0% for 60° and - 22% for 90°. For flexion, the difference to the uninjured side was measured 5% for 30°, -7% for 60° and - 12% for 90°. Median CMS was 75 (66-82) for the operated extremity compared to 82 (77-90) for the uninjured side. Age- and gender-adapted CMS was calculated 88 (79-99) vs. 96 (89-107). Median OSS was 47 (40-48). DASH was 26 (15-36). EQ-5D-5 L VAS ranged from 81 to 95 with a median of 90. The median difference of the deltoid muscle area on MRI was 2% (-21% to + 53%) compared to the uninjured side. No fatty degeneration of the deltoid muscle was observed. The weaker central part of the distal deltoid insertion was exclusively perforated by the plate, leaving the strong anterior and posterior parts of the insertion intact in all patients. CONCLUSIONS: MILPOH was associated with good functional and subjective outcome. Minor impairment of abduction strength was observed with increasing abduction angles. The reason for this impairment is unclear since MILPOH did not affect the structural quality of the deltoid muscle and the integrity of the strong anterior and posterior parts of its insertion remained intact. TRIAL REGISTRATION: 26/05/2023: ISRCTN51786146.

Anterior deltoid muscle reflection using a deltopectoral approach is safe and does not influence outcome of reverse shoulder arthroplasty.

BACKGROUND: The deltopectoral approach is well accepted for shoulder arthroplasty procedures. The extended deltopectoral approach with detachment of the anterior deltoid from the clavicle allows increased joint exposure and can protect the anterior deltoid from traction injury. The efficacy of this extended approach has been demonstrated in anatomic total shoulder replacement surgery. However, this has not been shown in reverse shoulder arthroplasty (RSA). The primary aim of this study was to evaluate the safety of the extended deltopectoral approach in RSA. The secondary aim was to evaluate the performance of the deltoid reflection approach in terms of complications and surgical, functional, and radiologic outcomes up to 24 months after surgery. METHODS: A prospective, nonrandomized comparative study was performed between January 2012 and October 2020 including 77 patients in the deltoid reflection group and 73 patients in the comparative group. The decision for inclusion was based on patient and surgeon factors. Complications were recorded. Patients were followed up for ≥24 months to evaluate their shoulder function and undergo ultrasound evaluation. Functional outcome measures included the Oxford Shoulder Score, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, pain intensity (rated on visual analog scale [VAS] from 0 to 100), and range of motion (forward flexion, abduction, and external rotation). A regression analysis was performed to evaluate any factors of influence on the VAS score. RESULTS: There were no significant differences in the complication rate between the 2 groups (14.5% in deltoid reflection group and 13.8% in comparative group, P = .915). Ultrasound evaluation was available in 64 patients (83.1%), and no proximal detachment was observed. In addition, there were no significant differences in functional outcome measures both preoperatively and at 24 months after surgery between the groups assessed based on the mean VAS pain score, Oxford Shoulder Score, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, forward flexion, abduction, and external rotation. Adjustment for possible confounders in a regression model indicated that only prior surgery significantly influenced the VAS pain score after surgery (P = .031; 95% confidence interval, 0.574-11.67). Deltoid reflection (P = .068), age (P = .466), sex (P = .936), use of glenoid graft (P = .091), prosthesis manufacturer (P = .382), and preoperative VAS score (P = .362) were not of influence. DISCUSSION: The results of this study show that an extended deltopectoral approach for RSA is safe. Selected reflection of the anterior deltoid muscle improved exposure and prevented anterior deltoid muscle injury followed by reattachment. Patients had similar functional scores preoperatively and at 24 months postoperatively compared with a comparative group. Furthermore, ultrasound evaluation showed intact reattachments.

Functional outcome and CEUS-assessed deltoid muscle vitality after fracture-specific versus standard prosthetic design in reverse shoulder arthroplasty for trauma.

Functional outcome after reverse-shoulder-arthroplasty (RSA) in proximal humerus fractures (PHF) depends on deltoid muscle integrity and successful reattachment of the tuberosities for best possible recovery of rotator-cuff function. In this monocentric, prospective, randomized, controlled trial we investigated whether a reverse-fracture-prosthesis (RFP) with a metaphyseal fenestrated stem achieved superior shoulder and muscle function compared to a common reverse-prosthesis (RP) design for patients with PHF. Our hypothesis was that patients with RFP may achieve a superior healing rate of the greater tuberosity (GT) compared to patients receiving RP, which translates to significantly higher clinical outcome and functional scores as well as differences in deltoid muscle microperfusion. Forty-four patients with PHF were randomized preoperatively to one of the prosthesis types in RSA between 2018 and 2020 (22 with RFP and 22 with RP) and prospectively assessed 6 months after surgery. We assessed osteointegration of the GT with radiographs 1 day and 6 months postoperatively and examined shoulder function and patient satisfaction by using established shoulder scores. A contrast-enhanced ultrasound (CEUS) examination of both shoulders was performed to quantify intramuscular blood flow and evaluate vitality of the deltoid muscle. None of the functional and psychosocial scores or radiographs and ultrasound examinations showed significant differences between the RSA designs. The constant-Murley score (p = 0.384) and active anterior-elevation-abduction, and external rotation were comparable between the RFP and RP group. Similar healing rates of the GT were observed (p = 0.655). CEUS-assessed deltoid microperfusion revealed equivalent muscle vitality for both groups (p = 0.312). Level of evidence: Level II; Randomized Controlled Trial; Treatment Study. Clinical significance: The radiographic evaluation for the investigation of the GT healing rate indicates that the proclaimed benefits of the fracture prosthesis with fenestration design might not be as great as expected.

Chronic intramuscular calcific tendinitis of the deltoid muscle.

Calcific tendinitis is a potentially symptomatic disorder characterized by calcium deposits in the substance of the tendon. Although this condition can occur in any tendinous tissue throughout the human body, calcium deposition commonly occurs at tendon insertions near the bone-tendon junction. The musculotendinous junction of the deltoid muscle has peculiarly dense intramuscular tendons to which muscle fibers attach obliquely to create muscular strength. Given that the intramuscular tendons themselves, which form the consecutive part from the insertion, are subjected to unpredictable stress load or microtrauma similar to tendon insertions, it is reasonable to assume that calcific tendinitis could also occur at the intramuscular tendons. Here we report a case of chronic symptomatic calcium deposition in the lateral part of the deltoid muscle between the origin and the insertion, which was eventually surgically removed and confirmed as intramuscular calcific tendinitis.

Anterior deltoid muscle tension quantified with shear wave ultrasound elastography correlates with pain level after reverse shoulder arthroplasty.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) leads to medialization and distalization of the centre of rotation of the shoulder joint resulting in lengthening of the deltoid muscle. Shear wave ultrasound elastography (SWE) is a reliable method for quantifying tissue stiffness. The purpose of this study was to analyse if deltoid muscle tension after RSA correlates with the patients' pain level. We hypothesized that higher deltoid muscle tension would be associated with increased pain. MATERIAL AND METHODS: Eighteen patients treated with RSA were included. Constant score (CS) and pain level on the visual analogue scale (VAS) were analysed and SWE was performed on both shoulders. All three regions of the deltoid muscle were examined in resting position and under standardized isometric loading. RESULTS: Average patient age was 76 (range 64-84) years and average follow-up was 15 months (range 4-48). The average CS was 66 points (range 35-89) and the average pain level on the VAS was 1.8 (range 0.5-4.7). SWE revealed statistically significant higher muscle tension in the anterior and middle deltoid muscle region in patients after RSA compared to the contralateral non-operated side. There was a statistically significant correlation between pain level and anterior deltoid muscle tension. CONCLUSION: SWE revealed increased tension in the anterior and middle portion of the deltoid muscle after RSA in a clinical setting. Increased tension of the anterior deltoid muscle portion significantly correlated with an increased pain level. SWE is a powerful, cost-effective, quick, dynamic, non-invasive, and radiation-free imaging technique to evaluate tissue elasticity in the shoulder with a wide range of applications. LEVEL OF EVIDENCE: Diagnostic study, Level III.

Contribution of shear wave elastography in evaluation of the deltoid in reverse shoulder arthroplasty: reproducibility study and preliminary results.

AIMS: The current difficulty of reverse shoulder arthroplasty (RSA) is soft tissue management, and adequate deltoid tension and at present there is no consensus and available tools (X-ray, MRI, EMG) remain difficult to apply in clinical follow-up. The objective of this study was (1) to determine reliability and feasibility of deltoid elasticity assessment using ultrasound elastographyand (2) to assess the change of deltoid stiffness after RSA by comparing shear wave speed (SWS) between healthy and RSA shoulders. MATERIAL AND METHODS: Twenty-six healthy (native shoulder, painless and complete range of motion) subjects and twelve patients with RSA were included. Two independent investigators performed 3 measurements on each segment. Measurements were bilateral. Anterior segment was also evaluated at 45° and 60° of passive abduction. Reliability and feasibility have been assessed (ISO5725-standard). RESULTS: Coefficient of measurements variation was less than 6.1% and 0.13 m/s. In the healthy group, SWS was not significantly different between anterior and middle segments; however, the SWS of the posterior segment was significantly lower than others (p<0.0001). In abduction position, compared to the rest position, SWS of the anterior segment decreased at 45° abduction (p=0.0003) and increased at 60° abduction (p<0.0001). Variability of measurement was higher in the RSA group. No significant difference was found between the SWS measurement of the operated and non-operated side. SWS measurements of the operated side of the anterior and middle segment were significantly higher compared to the healthy group. In abduction position, compared to rest position, no difference in SWS of the anterior segment was found at 45° abduction (p=0.71) and nor at 60° abduction (p=0.75). CONCLUSION: This study demonstrated feasibility and reliability of shoulder assessment with shear wave elastography. Reference values for asymptomatic patients can already be used in future studies on shoulder pathology and surgery.

Reversed shoulder arthroplasty leads to significant histological changes of the deltoid muscle: a prospective intervention trial.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) shows promising short- and mid-term results in cuff tear arthropathy. However, functional impairments are described in long-term findings. Micromorphological changes in the periarticular musculature could be in part responsible for this, but have not yet been analysed. Thus, histological changes of the deltoid muscle and their association to the functional outcome were evaluated in this study. MATERIAL AND METHODS: A total of 15 patients treated with RSA were included in this prospective study. Functional outcome was assessed using the Constant Score (CS) and the DASH (disabilities of the arm, shoulder and hand) Score before RSA and after a mean follow-up of 12 months. Deltoid muscle biopsies were harvested intraoperatively and 12 months postoperatively. Mean deltoid muscle fibre area (MMFA) was calculated histologically after haematoxylin-eosin staining. RESULTS: Postoperative shoulder function significantly improved within 12 months (CS: Δ 37.4 ± 22.6, p = 0.001; DASH: Δ 27.1 ± 29.1, p = 0.006). The MMFA significantly decreased (p = 0.02), comparing the results from the intraoperative biopsy (MMFA: 8435.8 µm2, SD ± 5995.9 µm2) to the 12 months biopsy (MMFA: 5792. µm2, SD ± 3223.6 µm2). No correlation could be found between the functional score results and MMFA. CONCLUSION: Signs of deltoid muscle changes in terms of a reduced MMFA can be detected 1 year after RSA and thus already a long time before long-term functional impairments become apparent. Further studies with larger patient series and longer follow-up periods as well as extended histological assessments and simultaneous radiological examinations are required.

The effect of glenosphere lateralization and inferiorization on deltoid force in reverse total shoulder arthroplasty.

BACKGROUND: A medialized center of rotation (COR) in reverse total shoulder arthroplasty (RTSA) comes with limitations such as scapular notching and reduced range of motion. To mitigate these effects, lateralization and inferiorization of the COR are performed, but may adversely affect deltoid muscle force. The study purposes were to measure the effect of RTSA with varying glenosphere configurations on (1) the COR and (2) deltoid force compared with intact shoulders and shoulders with massive posterosuperior rotator cuff tears (PS-RCT). We hypothesized that the highest deltoid forces would occur in shoulders with PS-RCT, and that RTSA would lead to a decrease in required forces that is further minimized with lateralization and inferiorization of the COR but still higher compared with native shoulders with an intact rotator cuff. METHODS: In this study, 8 cadaveric shoulders were dissected leaving only the rotator cuff muscles and capsule intact. A custom apparatus incorporating motion capture and a dynamic tensile testing machine to measure the changes in COR and deltoid forces while simultaneously recording glenohumeral abduction was designed. Five consecutive testing states were tested: (1) intact shoulder, (2) PS-RCT, (3) RTSA with standard glenosphere, (4) RTSA with 4 mm lateralized glenosphere, and (5) RTSA with 2.5 mm inferiorized glenosphere. Statistical Parametric Mapping was used to analyze the deltoid force as a function of the abduction angle. One-way repeated-measures within-specimens analysis of variance was conducted, followed by post hoc t-tests for pairwise comparisons between the states. RESULTS: All RTSA configurations shifted the COR medially and inferiorly with respect to native (standard: 4.2 ± 2.1 mm, 19.7 ± 3.6 mm; 4 mm lateralized: 3.9 ± 1.2 mm, 16.0 ± 1.8; 2.5 mm inferiorized: 6.9 ± 0.9 mm, 18.9 ± 1.7 mm). Analysis of variance showed a significant effect of specimen state on deltoid force across all abduction angles. Of the 10 paired t-test comparisons made between states, only 3 showed significant differences: (1) intact shoulders necessitated significantly lower deltoid force than specimens with PS-RCT below 42° abduction, (2) RTSAs with standard glenospheres required significantly lower deltoid force than RTSA with 4 mm lateralized glenospheres above 34° abduction, and (3) RTSAs with 2.5 mm inferiorized glenospheres had significantly lower deltoid force than RTSA with 4 mm of glenosphere lateralization at higher abduction angles. CONCLUSIONS: RTSA with a 2.5 mm inferiorized glenosphere and no additional lateralization resulted in less deltoid force to abduct the arm compared with 4 mm lateralized glenospheres. Therefore, when aiming to mitigate downsides of a medialized COR, an inferiorized glenosphere may be preferable in terms of its effect on deltoid force.

Infraspinatus and deltoid length and patient height: implications for lateralization and distalization in reverse total shoulder arthroplasty.

BACKGROUND: Restoration of muscular strength is predicated on restoration of muscle length. The purpose of this study was to describe infraspinatus and deltoid length preoperative to reverse total shoulder arthroplasty (RTSA) to guide distalization and lateralization to restore preoperative muscle length. METHODS: This was a retrospective radiographic study. We measured the infraspinatus length on preoperative computed tomographic images and the deltoid length on preoperative radiographs. For all measurements, reliability was first established by comparing measurements between 2 observers, and intraclass correlation coefficients (ICCs) were calculated. We then calculated descriptive statistics for these muscle lengths and developed a formula to predict these muscle lengths from patient demographics. RESULTS: We measured infraspinatus length in 97 patients and deltoid length in 108 patients. Inter-rater reliability was excellent, with all ICCs >0.886. The mean infraspinatus length was 15.5 cm (standard deviation 1.3) and ranged from 12.6-18.9 cm, whereas the deltoid length was 16.2±1.7 cm and ranged from 12.5-20.2 cm. Both infraspinatus (r = 0.775, P < .001) and deltoid length (r = 0.717, P < .001) were highly correlated with patient height but did not differ between diagnoses. Formulae developed through linear regression allowed prediction of muscle length to within 1 cm in 78% and within 2 cm in 100% for the infraspinatus and 60% and 88% for the deltoid. CONCLUSION: Deltoid and infraspinatus length are variable but highly correlated with patient height. To maintain tension, 2 mm of lateralization and distalization should be added for every 6 inches (∼15 cm) of height above average for a Grammont-style RTSA.

Short-term Clinical Outcome of Proximal Humeral Fracture Fixation Using Minimally Invasive Trans-Deltoid Approach.

BACKGROUND: This study examined the clinical outcomes of fixation of displaced fractures of the proximal humerus using a trans-deltoid approach. MATERIAL AND METHODS: Twenty patients (13 male and 7 female) were treated with this technique, with a mean age of the patients of 38.85 years (range, 19 to 64 years). All patients were followed up for at least twelve months and were evaluated according to the Constant shoulder score. RESULTS: The mean Constant Shoulder score was 87.45, ranging from 63 to 100. Ten patients (50%) had excellent results, four patients (20%) had good results, three patients (15%) had satisfactory results, and three had adequate results (15%). There was a statistically significant difference between the type of the fracture and the final score (p=0.013), where 3-part fractures with impaction (11-B1), either valgus or varus impaction, showed higher scores than those without impaction. Four patients presented with post-operative complications varying from superficial infection to radial nerve palsy. CONCLUSIONS: 1. The trans-deltoid approach was a safe and reliable alternative to the delta-pectoral approach for the treatment of displaced proximal humerus fractures. 2. The impacted (11-B1) fracture type was a signifi-cant contributing factor in terms of good functional outcomes.

Retrieval of a retained guide wire from the deltoid muscle-A rare and delayed presentation post cardiac resynchronization therapy lead replacement.

BACKGROUND AND AIMS: Fracture and retention of a guidewire after cardiac resynchronization therapy device implantation has not been reported in the literature so far, although it is an uncommon but known complication during cardiac interventions like percutaneous coronary interventions and other cardiac catheterization procedures. METHODS: A 53 years old female patient presented with severe pain over the left arm and shoulder for a period of 1 to 2 days. The patient had a history of dilated cardiomyopathy with severe left ventricular dysfunction and underwent cardiac resynchronization therapy device implant 3 years back with subsequent lead replacement 6 months back due to lead dysfunction. On evaluation, a coronary guidewire which might have fractured and been retained inadvertently during previous surgical procedure, was discovered in her deltoid muscle. Her symptoms were attributed to the guide wire which may have been aggravated by the movements of her arm. Emergency surgical exploration was done and the guidewire was removed. RESULTS AND CONCLUSION: We are reporting a case of unlikely and unusual delayed presentation of retained intervention guide-wire post cardiac resynchronization therapy, which was retrieved from the left deltoid muscle.

Comparison between minimally invasive deltoid-split and extended deltoid-split approach for proximal humeral fractures: a case-control study.

BACKGROUND: With the rapid aging of the population, the incidence of proximal humeral fracture (PHF) has increased. However, the optimal method for open reduction and internal fixation (ORIF) remains controversial. METHODS: We performed a retrospective analysis of patients with PHF who underwent locking plate internal fixation at our institution from January 2016 to December 2018. Patients were divided into two groups based on the surgical approach used: an expanded deltoid-split approach group (ORIF group) and minimally invasive deltoid-split approach group (minimally invasive percutaneous plate osteosynthesis, [MIPPO] group). The groups were compared in terms of demographic and perioperative characteristics, and clinical outcomes. RESULTS: A total of 115 cases of PHF were included in our study, of which 64 cases were treated using the minimally invasive deltoid-split approach and 51 using the extended deltoid-split approach. Fluoroscopy was performed significantly less frequently in the ORIF group and the surgical duration was shorter. However, the postoperative visual analogue scale (VAS) pain score and duration of postoperative hospital stay were significantly higher compared to the MIPPO group. Moreover, secondary loss was significantly less extensive in the ORIF group compared to the MIPPO group, while there was no significant group difference in fracture healing time, Constant shoulder score, or complications at the last follow-up visit. CONCLUSIONS: The clinical outcomes associated with both the minimally invasive and extended deltoid-split approaches were satisfactory. The data presented here suggest that the extended deltoid-split approach was superior to the minimally invasive deltoid-split approach in terms of operational time, fluoroscopy, and secondary loss of reduction, while the minimally invasive approach was superior in terms of postoperative pain and hospital stay. Accordingly, neither procedure can be considered definitively superior; the optimal surgical procedure for PHF can only be determined after full consideration of the situation and requirements of the individual patient.

Trapezius Transfer to Restore Shoulder Function in Traumatic Brachial Plexus Injury: Revisited and Modified.

Background: Trapezius transfer has shown promise to restore shoulder movements and has stood through the passage of time. We here in describe a modification of trapezius transfer technique and review the current literature available. Methods: The modified trapezius transfer in which the trapezius muscle is extended with folded tensor fascia lata graft and attached as distally possible to the deltoid insertion was done in twelve patients at tertiary health care centre in India. Post-operative splinting and staged physiotherapy were given. Results: Results were described in the form of improvement in degree of shoulder abduction and Disabilities of the Arm, Shoulder and Hand (DASH) score. Six months post-surgery there were improvement in shoulder abduction and DASH score with mean 116 degrees (10-180 degree) and 38 (23-58) respectively. One patient showed poor results due to poor compliance in post-operative period. There were no major complications observed. Conclusions: The modified technique of trapezius transfer described here is a feasible option with good biomechanical outcomes. The technique is simple and can be adopted easily by emerging brachial plexus surgeon as a technique for secondary reconstruction of shoulder joint.

Functional evaluation following deltoid muscle resection in patients with soft tissue sarcoma.

BACKGROUND: The present study aimed to determine functional outcomes in patients undergoing deltoid muscle resection for soft tissue sarcoma. METHODS: Between 2002 and 2014, 18 patients with soft tissue sarcoma of the shoulder who underwent wide resection including the deltoid muscle, and were followed up for more than 12 months, were retrospectively included in the study. In all, 11 patients were male and 7 were female. The median age was 59 years, median follow-up duration was 37 months. The extent of resection of deltoid muscle, with or without rotator cuff damage, reconstruction methods, adjuvant therapy, oncological outcomes, and the International Society of Limb Salvage (ISOLS) score as functional outcomes were analyzed. RESULTS: Six patients underwent total resection, and twelve underwent partial resections of deltoid muscle. The rotator cuff was resected in four patients. Soft tissue reconstruction was performed in 17 patients using a pedicled latissimus dorsi muscle flap. Two local recurrences and three distant metastases occurred during follow-up. Median overall survival was 72 months. The mean ISOLS score was 25.0 points (±4.6points). Univariate analysis revealed that there was no significant difference in ISOLS score regarding the extent of deltoid muscle resection. Multivariate analysis identified only combined resection of the rotator cuff as a significant prognostic factor for poor functional outcomes (P < 0.001). CONCLUSIONS: The extent of resection of the deltoid muscle might not affect the functional outcomes determined by ISOLS score. If the rotator cuff is resected concurrently, satisfactory functional outcomes might not be obtained.

Relation between preoperative electromyographic activity of the deltoid and upper trapezius muscle and clinical results in patients treated with reverse shoulder arthroplasty.

BACKGROUND: If patients susceptible to poor clinical outcomes could be predicted before reverse shoulder arthroplasty (RSA), it would help to set reasonable postsurgical patient expectations in the preoperative setting. Our hypothesis was that the preoperative electromyographic (EMG) activity of the deltoid and upper trapezius muscles would be correlated with clinical outcomes of patients undergoing RSA. METHODS: EMG activity of the deltoid and upper trapezius muscles was measured in 25 patients scheduled to undergo RSA during 3 motions: shrugging, forward flexion, and abduction. Their postoperative clinical results were assessed prospectively during regular outpatient visits, including strength, active range of motion (ROM), pain, and functional scores. The correlations between the preoperative EMG activities and clinical results were analyzed. RESULTS: Postoperative shoulder strength after RSA was increased in patients with greater preoperative EMG activity of the middle deltoid and upper trapezius. Preoperative EMG activity of the anterior or middle deltoid muscle was associated with active ROM in flexion or abduction, whereas EMG activity of the posterior deltoid was associated with active ROM in external rotation. CONCLUSIONS: Shoulder strength after RSA was positively correlated with preoperative EMG activity of the deltoid and upper trapezius. Active ROM after RSA was positively correlated with preoperative EMG activity of the deltoid. Therefore, preoperative EMG measurements of the deltoid and upper trapezius may predict clinical outcomes after RSA.

Transarticular external fixation versus deltoid ligament repair in treating SER IV ankle fractures: a comparative study.

BACKGROUND: The topic that whether the injured deltoid ligament should be repaired when associated with ankle joint fractures is still discussed. The objective of this study was to compare the clinical effect of open reduction and internal fixation (ORIF) with deltoid ligament repair (DLR) or transarticular external fixation (TEF) in treating supination-external rotation type IV (SER IV) ankle fractures. METHODS: Between January 2012 and December 2015, 43 patients were diagnosed as SER IV ankle fractures, 20 underwent ORIF and transarticular external fixation (TEF) without DLR (group 1), 23 were treated with ORIF and DLR (group 2). The pre- and post-operative radiographic examination were performed, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analog scale (VAS), the Medical Outcomes Short Form 36-item questionnaire score (SF-36), and the ankle range of motion (ROM) were used for functional evaluation. RESULTS: In both groups, the three scores improved significantly after surgery, but there was no significant difference between the two groups. At 6 weeks after surgery, patients in group 2 had better ankle ROM than group 1 (29.35 ± 2.033 vs. 40.35 ± 3.550, P <  0.001), but there was no difference at 12 months postoperatively. No cases of bone nonunion or post-traumatic arthritic changes were seen during the follow-up. Patients in group 1 required a shorter time to achieve fracture union than patients in group 2. CONCLUSIONS: ORIF with TIF is an optional strategy to manage SER IV ankle fractures as it achieves comparable functional results to ORIF with DLR. It also allows patients to start relatively earlier weight-bearing and may promote fracture union.

Shoulder girdle resection: surgical technique modification and introduction of a new classification system.

OBJECTIVE: Different classification systems for surgical tumor resections in the proximal humerus and scapula have been described, but none are specific or have been recently revised. The purpose of this article is to report modified surgical techniques and a new classification system for resections in the humerus and scapula. METHODS: Thirty-two patients with shoulder girdle bone tumors were operated upon. Two separate new classifications were assigned to resections in the humerus (types I-IV) and scapula (types I-III). An annotation is added to signify deltoid preservation (A) or sacrifice (B). Modified surgical techniques were devised. RESULTS: For extra-articular resections of the proximal humerus, we show that sacrificing the acromion and coracoid process is not required. Preservation of these structures can improve cosmetic shoulder outcome. For tumors with no large medial component, we show that there is no need to detach the muscle attachment from the coracoid process allowing earlier elbow extension postoperatively. After a mean follow-up period of 46 months, only two patients developed local recurrence. Postoperative infection was seen in two and stem loosening in one patient. The average MSTS functional score for all patients was 83%. CONCLUSION: Our modified surgical techniques saved structures which were unnecessarily resected with no advantage in surgical series. We reserved the integrity of more muscular tissues and attachments leading to less restriction during the rehabilitation process. This new classification system is realistic, easy to implement, and applicable to all patients.

Deltoid-split approach versus deltopectoral approach for proximal humerus fractures: A systematic review and meta-analysis.

PURPOSE: To investigate the evidence of deltoid-split approach (DS) versus deltopectoral approach (DP) in treatment of proximal humerus fractures from current RCT and prospective literatures. METHODS: The electronic literature database of Pubmed, Embase, and Cochrane library was searched at December 2017. The data complications (including implant failure, humeral head necrosis, infection, radiological adverse events, nonunion rate, subacromial impingement, and damage of the axillary nerve), functional outcomes (including Constant, NEER, DASH, ADL, VAS score), operation time, hospital stay and intraoperative blood loss were extracted and analyzed by STATA 11.0 software. RESULTS: Three RCTs and three prospective comparative studies were included in this meta-analysis. The meta-analysis showed that the DS group had a significantly low humeral head necrosis rate and short operation time. No significant difference was found in total complication rate, functional outcome, and other Perioperative parameters between DS and DP groups. CONCLUSION: The prospective evidence suggested that DS approach for proximal humerus fractures had less humeral head necrosis and short operation time than DP approach. Both DS and DP approach had similar results in functional outcomes, total complication, VAS, and hospital stay.

Do we need to stabilize and treat the os acromiale when performing reverse shoulder arthroplasty?

INTRODUCTION: The purpose of this study is to investigate the incidence of os acromiale in patients who had reverse shoulder arthroplasty (RSA) for rotator cuff tear arthropathy and the effect of presence of os acromiale on the functional results. HYPOTHESIS: We hypothesize than in the presence of os acromiale, the contraction strength of the deltoid would decrease due to the dynamic downward depression of the bony fragment leading to less favorable clinical results. MATERIAL AND METHOD: A total 46 patients with a mean age of 70.8 who had RSA and a minimum follow-up of 24 months were included in this study. Preoperative radiographs, computerized tomography scans and magnetic resonance images were examined to determine the presence of os acromiale. RESULTS: A total of 10 patients out of 46 (22%) with os acromiale, all of which were of mesoacromion type, were followed up for 59.7 months. While both groups had significant improvements in Constant, Q-DASH and VAS scores compared to their preoperative status, a significant difference between the groups could not be found. The radiological evaluation showed that the average acromiohumeral distance significantly increased postoperatively in both groups. The acromiohumeral distance was significantly shorter in patients with os acromiale. DISCUSSION: While the presence of os acromiale does not have an adverse effect on the clinical results of the RSA, the loose fragment can migrate distally in the postoperative period due to the tension in the deltoid. LEVEL OF EVIDENCE: III, case-control study.