Scapula fractures: functional anatomy, clinical assessment and management.

Fractures of the scapula are rare injuries, accounting for 3-5% of all shoulder girdle fractures. They are frequently the result of high energy trauma and often present with concurrent and life-threatening injuries to adjacent structures, leading to significant morbidity and mortality. Patients presenting with scapula fractures must receive a thorough and systematic clinical assessment as directed by national trauma guidelines. Appropriate imaging is essential in delineating fracture morphology and should at the very least include anteroposterior, anteroposterior oblique (Grashey) and axillary or scapula 'Y' view of the shoulder. Computed tomography imaging with three-dimensional reconstruction allows better delineation of the fracture morphology and helps with surgical planning. A lack of randomised controlled trials comparing the efficacy of conservative and operative management of scapula fractures has resulted in limited consensus for surgical indications. Nevertheless, most extra-articular fractures can be managed conservatively while intra-articular fractures of the glenoid frequently require surgical fixation.

Assessment of micromotion at the bone-bone interface after coracoid and scapular-spine bone-block augmentation for the reconstruction of critical anterior glenoid bone loss-a biomechanical cadaver study.

BACKGROUND: Glenoid bone loss is among the most important risk factors for recurrent anterior shoulder instability, and a bony reconstruction is recommended in cases of critical bone loss (> 15%). The commonly used surgical techniques, including coracoid transfer, are associated with considerable complications. The aim of this study was to assess the motion at the glenoid-bone-block interface after coracoid and spina-scapula bone-block reconstruction of the anterior glenoid. METHODS: Twelve cadaveric shoulders were tested. A 20% bone defect of the anterior glenoid was created, and the specimens were randomly assigned for glenoid augmentation using a coracoid bone block (n = 6) or a scapular spine bone block (n = 6). The glenoid-bone interface was cyclically loaded for 5000 cycles with a force of 170 N. The micromotion was tracked using an optical measurement system (GOM ARMIS) and was evaluated with the GOM Correlate Pro software. RESULTS: The most dominant motion component was medial irreversible displacement for the spina-scapula (1.87 mm; SD: 1.11 mm) and coracoid bone blocks (0.91 mm; SD: 0.29 mm) (n.s.). The most medial irreversible displacement took place during the first nine cycles. The inferior reversible displacement was significantly greater for spina-scapula bone blocks (0.28 mm, SD: 0.16 mm) compared to coracoid bone blocks (0.06 mm, SD: 0.10 mm) (p = 0.02). CONCLUSIONS: The medial irreversible displacement is the dominant motion component in a bone-block reconstruction after a critical bone loss of the anterior glenoid. The spina-scapula and coracoid bone blocks are comparable in terms of primary stability and extent of motion. Thus, spina-scapula bone blocks may serve as alternatives in bony glenoid reconstruction from a biomechanical point of view.

Scapulohumeral rhythm in shoulders with reverse shoulder arthroplasty measured with a new portable three-dimensional scapular kinematics assessment system.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a valid and increasingly popular treatment option in eccentric arthrosis and cuff arthropathy. We know that the deltoid is the motor of RSA. However, the role of scapular motion has been poorly documented in the literature. The aim of our study is to analyze and quantify the role of the scapular contribution in the functional outcome of patients undergoing RSA. MATERIALS AND METHODS: Fourteen patients who underwent primary RSA were included in the study. In all cases, a reverse prosthesis with lateralizing stem was implanted. All patients underwent clinical examination, video recording, and motion analysis. X-ray and postoperative CT examinations were collected to evaluate positioning and any loosening. ShowMotion (NCS Lab srl, Modena, Italy) 3D kinematic tracking system was used to evaluate and measure the scapular motion in 3 planes. RESULTS: All patients show substantial amount of posterior tilting and lateral rotation starting at 30° in forward elevation. A further difference is the anticipation of the retraction during the range of motion in the RSA side. The contribution of scapular motion in the RSA shoulder was greater than in the healthy shoulder. In patients with bilateral RSA, the contribution of scapular motion was higher in tilting and lateral rotation in the worse shoulder side in terms of range of motion. This means that to compensate for the loss of glenohumeral motion in RSA, more scapula-thoracic motion is needed to obtain the same thoraco-humeral elevation angle. CONCLUSIONS: In the light of what has been measured, the post-RSA scapular kinematics has typical characteristics that must be achieved in order to obtain a good functional outcome. We can conclude that on the RSA side, the patients anticipate upward rotation both in flexion and abduction. The contribution of the upward rotation to elevation in the RSA group is therefore more significant. In addition to this, to facilitate elevation movements, there is an anticipation of the scapular retraction and a more prominent tilt resulting in different scapular kinematics. The analysis of scapular motion could be useful in the postoperative follow-up of patients undergoing RSA surgery and improve adaptative physiotherapy protocols. It potentially can even be included in future arthroplasty planning systems.

Scapular winging due to rhomboid muscle paralysis: clinical assessment of 4 cases and anatomic study of the dorsal scapular nerve.

BACKGROUND: A rare cause of scapular winging is rhomboid muscle paralysis secondary to dorsal scapular nerve (DSN) neuropathy. This paralysis causes winging of the medial border of the scapula with lateral rotation of its inferior angle. We report a series of 4 clinical cases of isolated DSN compression and the results of a specific rehabilitation protocol. METHODS: A continuous clinical series of 4 patients with isolated rhomboid muscle deficiency was analyzed. Two patients were men and 2 were women, with a mean age of 40 years (range, 33-51 years). Three patients were right-handed and 1 was left-handed. Scapular winging always affected the dominant side. Two patients had occupations involving heavy physical work. The sports practiced involved exertion of the arms (dancing, boxing, gymnastics, muscle strengthening). A specific rehabilitation protocol was offered to the patients. In addition, 6 fresh cadaver dissections were performed to reveal possible DSN compression. Potential areas of compression were identified, in particular when the arm was raised. RESULTS: The 4 patients presented with isolated DSN neuropathy were confirmed by electroneuromyographic testing. Total correction of scapular winging was not obtained in any patient. Three patients experienced residual pain with a neuropathic pain by the questionnaire for a Diagnosis of Neuropathic Pain (DN4) score of 2. The mean Quick-Disabilities of the Arm, Shoulder and Hand (DASH) score after treatment was 31.8 of 100. The mean ASES score was 56.2. Only 1 patient agreed to rehabilitation in a specialized center and underwent follow-up electroneuromyography. Signs of rhomboid muscle denervation were no longer present and distal motor latencies had become normal. In all cadaver dissections, the DSN originated from the C5 nerve root and did not pass through the middle scalene muscle. We identified a site of dynamic compression of the DSN by the upper part of the medial border of the scapula when the arm was raised. DISCUSSION: DSN compression is conventionally attributed to the middle scalene muscle, but it is noteworthy that our study reveals the possibility of dynamic compression of the nerve by the proximal part of the medial border of the scapula, which occurs when the arm elevation is above 90°. CONCLUSION: Our study reveals the possibility of dynamic compression of the DSN by the proximal part of the medial border of the scapula, which occurs when the arm is raised above 90°. In the absence of a surgical solution, conservative treatment is fundamental and requires management in a rehabilitation center with intervention by a multidisciplinary team.

Development and ex-vivo assessment of a novel patient specific guide and instrumentation system for minimally invasive total shoulder arthroplasty.

OBJECTIVE: To develop and assess a novel guidance technique and instrumentation system for minimally invasive short-stemmed total shoulder arthroplasty that will help to reduce the complications associated with traditional open replacement such as poor muscle healing and neurovascular injury. We have answered key questions about the developed system including (1) can novel patient-specific guides be accurately registered and used within a minimally invasive environment?; (2) can accuracy similar to traditional techniques be achieved? METHODS: A novel intra-articular patient-specific guide was developed for use with a new minimally invasive posterior surgical approach that guides bone preparation without requiring muscle resection or joint dislocation. Additionally, a novel set of instruments were developed to enable bone preparation within the minimally invasive environment. The full procedure was evaluated in six cadaveric shoulders, using digitizations to assess accuracy of each step. RESULTS: Patient-specific guide registration accuracy in 3D translation was 2.2±1.2mm (RMSE±1 SD; p = 0.007) for the humeral component and 2.7±0.7mm (p<0.001) for the scapula component. Final implantation accuracy was 2.9±3.0mm (p = 0.066) in translation and 5.7-6.8±2.2-4.0° (0.001

Assessment of surgeon variability in preoperative planning of reverse total shoulder arthroplasty: a quantitative comparison of 49 cases planned by 9 surgeons.

BACKGROUND: Preoperative planning software is gaining utility in reverse total shoulder arthroplasty (RTSA), particularly when addressing pathologic glenoid wear. The purpose of this study was to quantify inter- and intrasurgeon variability in preoperative planning a series of RTSA cases to identify differences in how surgeons consider optimal implant placement. This may help identify opportunities to establish consensus when correlating plan differences with clinical data. METHODS: A total of 49 computed tomography scans from actual RTSA cases were planned for RTSA by 9 fellowship-trained shoulder surgeons using the same platform (Exactech GPS, Exactech Inc., Gainesville, FL, USA). Each case was planned a second time 6-12 weeks later. Variability within and between surgeons was measured for implant selection, version correction, inclination correction, and implant face position. Interclass correlation coefficients, and Pearson and Light's kappa coefficient were used for statistical analysis. RESULTS: There was considerable variation in the frequency of augmented baseplate selection between surgeons and between rounds for the same surgeon. Thresholds for augment use also varied between surgeons. Interclass correlation coefficients for intersurgeon variability ranged from 0.43 for version, 0.42 for inclination, and 0.25 for baseplate type. Pearson coefficients for intrasurgeon variability were 0.34 for version and 0.30 for inclination. Light's kappa coefficient for baseplate type was 0.61. CONCLUSIONS: This study demonstrates substantial variability both between surgeons and between rounds for individual surgeons when planning RTSA. Although average differences between plans were relatively small, there were large differences in specific cases suggesting little consensus on optimal planning parameters and opportunities to establish guidelines based on glenoid pathoanatomy. The correlation of preoperative planning with clinical outcomes will help to establish such guidelines.

Assessment of shoulder function following scapular free flap.

BACKGROUND: The scapular system free flap has been increasing in popularity to reconstruct short segment mandibular bony defects. It is important to assess donor site morbidities systematically. METHODS: Prospective cohort study using objective measures of range of motion (ROM) and shoulder strength were measured. Subjective disability was evaluated with validated questionnaires-Neck Disability Impairment Index and Shoulder Pain and Disability Index. RESULTS: Twenty-six patients were recruited-19 with scapular tip and 7 with lateral border scapular free flap. Decreased ROM on the operated side was noted for shoulder abduction, shoulder flexion, and external rotation. No significant difference was noted for shoulder extension. Strength was reduced for shoulder flexion, shoulder abduction, and external rotation. Subjective measurements did not indicate significant shoulder function disruption. CONCLUSION: Patients with scapular free flap reconstruction did not experience significant shoulder morbidity. Measures of shoulder ROM and power were objectively affected; however, subjective measures of shoulder disability were not significantly affected.

Assessment of anatomical and reverse total shoulder arthroplasty with the scapula-weighted Constant-Murley score.

AIM OF THE STUDY: To evaluate total (TSA) and reverse total shoulder arthroplasty (RTSA) using the Constant-Murley score (CMS) and the scapula-weighted (SW) CMS, an integrated outcome measure that takes into account the compensatory movements of the scapula. METHODS: Twenty-five consecutive patients, 12 with TSA and 13 with RTSA, underwent kinematic analysis before and after shoulder replacement. Measurements included flexion (FLEX) and abduction (ABD) for the humerus and Protraction-Retraction (PR-RE), Medio-Lateral rotation (ME-LA), and Posterior-Anterior tilting (P-A) for the scapula. They were recorded at baseline (T0) and at six (T1) and 12 months (T2). Reference data were obtained from 31 control shoulders. RESULTS: At T1, differences in CMS and SW-CMS were not significant in either group, whereas values at T2 were significantly lower in RTSA patients (p = 0.310 and p = 0.327, respectively). In TSA shoulders, the compensatory scapular movements in FLEX were all reduced from T0 to T2, whereas P-A was increased in ABD. In RTSA patients, the compensatory scapular movements in FLEX showed a general reduction at T1, with an increase in P-A at T2, whereas in ABD, all increased at T1 and decreased at T2 except for P-A, which did not decrease. DISCUSSION: The SW-CMS showed that the physiological scapulothoracic motion was not restored in TSA and RTSA patients; it may be used as a reference for the gradual progression of deltoid and scapular muscle rehabilitation. CONCLUSIONS: The worse CMS and SW-CMS scores found in RTSA patients at six months may be due to the biomechanics of the reverse prosthesis and to the weakness of deltoid and periscapular muscles.

Functional outcomes and clinical strength assessment after infraspinatus-sparing surgical approach to scapular fracture: Does it really make a difference?

BACKGROUND: Surgical treatment of scapular fractures with posterior approach is frequently associated with postoperative infraspinatus hypotrophy and weakness. The aim of this retrospective study is to compare infraspinatus strength and functional outcomes in patients treated with the classic Judet versus modified Judet approach for scapular fracture. PATIENTS AND METHODS: 20 cases with scapular neck and body fracture treated with posterior approach for lateral border plate fixation were reviewed. In 11 of 20 cases, we used the modified Judet approach (MJ group), and in 9 cases we used the classic Judet approach (CJ group). All fractures were classified according to the AO classification system. At follow-up examinations, patients had X-ray assessment with acromiohumeral distance (AHD) measurement, clinical evaluation, active range of motion (ROM) examination, Constant Shoulder Score, and Disability of the Arm, Shoulder and Hand (DASH) Score. Infraspinatus strength assessment was measured using a dynamometer during infraspinatus strength test (IST) and infraspinatus scapular retraction test (ISRT). RESULTS: Demographic data did not significantly differ between the CJ group and MJ group, except for mean follow-up, which was 4.15 years in the CJ group and 2.33 in the MJ group (p < 0.001). All X-ray examinations showed fracture healing. AHD was significantly decreased in the CJ group (p = 0.006). We did not find significant differences in active ROM between the MJ and CJ groups in the injured arm (p < 0.05). The Constant Score was 75.83 (±14.03) in the CJ group and 82.75 (±10.72) in the MJ group (p = 0.31); DASH Score was 10.16 in the CJ group and 6.25 in the MJ group (p = 0.49). IST showed mean strength of 8.38 kg (±1.75) in the MJ group and 4.61 kg (±1.98) in the CJ group (p = 0.002), ISRT test was 8.7 (±1.64) in the MJ group and 4.95 (±2.1) in the CJ group (p = 0.002). Infraspinatus hypotrophy was detected during inspection in six patients (five in the CJ group and one in the MJ group); it was related to infraspinatus strength weakness in IST and ISRT (p < 0.001). CONCLUSIONS: Infraspinatus-sparing surgical approach for scapular fracture avoids infraspinatus hypotrophy and external-rotation strength weakness. We suggest use of the modified Judet approach for scapular fracture and to restrict the classic Judet approach to only when the surgeon believes that the fracture is not easily reducible with a narrower exposure. LEVEL OF EVIDENCE: Level IV.

Influence of scapular tilt on radiographic assessment of the glenoid component after total shoulder arthroplasty: which radiographic landmarks are reliable?

BACKGROUND: Total shoulder arthroplasty has been shown to improve function and to reduce pain in cases of osteoarthritis. To assess loosening of the glenoid component, serial evaluation of frontal plane radiographs of the scapula has been established as the "gold standard." The aim of this study was to evaluate the reliability of different bone landmarks when the scapula is tilted compared with the ideal view. METHODS: Glenoid components were implanted into 6 human cadaveric scapulae. Radiographs were taken exactly anterior-posterior in the frontal plane as well as craniocaudal tilted (±15° and ±30°) and mediolateral tilted (±10° and ±20°). The following landmarks were evaluated: lateral margin of the scapula, medial margin of the scapula, floor of the fossa supraspinatus line, spine of the scapula line, glenoid fossa line, and coracoid base line. RESULTS: In evaluating the inclination of the glenoid component, the medial margin of the scapula had the best intraobserver and interobserver reliability with a variance for each of 2° ± 1° (P < .0001), whereas the lateral margin of the scapula had an acceptable intraobserver and interobserver reliability with a variance of 4° ± 1° and 3° ± 1°. In measuring medial migration, the glenoid fossa line had a significantly lower intraobserver and interobserver reliability than the coracoid base line (each 1 ± 0 mm vs. 3 ± 1 mm and 3 ± 2 mm; P < .0001). CONCLUSION: To assess the inclination of the glenoid component, the medial margin of the scapula has proven best, and the lateral margin of the scapula has acceptable reliability. For measuring medial migration, the coracoid base line has proven acceptable reliability, whereas the glenoid fossa line would be subject to change when osteolysis occurs at the glenoid.

Open Latarjet versus arthroscopic Latarjet: clinical results and cost analysis.

PURPOSE: The aim of this study was to compare the clinical results between open and arthroscopic Latarjet and perform a cost analysis of the two techniques. MATERIALS AND METHODS: A systematic review of articles present in PubMed and MEDLINE was performed in accordance with PRISMA guidelines. Studies concerning post-operative outcomes following Latarjet procedures for chronic anterior shoulder instability were selected for analysis. The clinical and radiographic results as well as the costs of the open and arthroscopic techniques were evaluated. RESULTS: Twenty-three articles, describing a total of 1317 shoulders, met the inclusion criteria: 17 studies were related to open Latarjet, and 6 to the arthroscopic technique. Despite the heterogeneity of the evaluation scales, the clinical results seemed very satisfactory for both techniques. We detected a statistically significant difference in the percentage of bone graft healing in favour of the open technique (88.6 vs 77.6 %). Recurrent dislocation was more frequent following open surgery (3.3 % after open surgery vs 0.3 % after arthroscopy), but this finding was biased by the large difference in follow-up duration between the two techniques. The direct costs of the arthroscopic procedure were double in comparison to open surgery (€2335 vs €1040). A lack of data prevented evaluation of indirect costs and, therefore, a cost-effectiveness analysis. CONCLUSIONS: The open and arthroscopic Latarjet techniques showed excellent and comparable clinical results. However, the much higher direct costs of the arthroscopic procedure do not seem, at present, to be justified by a benefit to the patient. LEVEL OF EVIDENCE: III.

Use of glenoid inclination angle for the assessment of unilateral congenital high scapula.

Little has been reported on the motion of the scapula in Sprengel's deformity. Fourteen patients with unilateral congenital high scapula underwent the Woodward procedure from 1986 to 2004. The median age of the patients at the time of surgery was 4.4 years and the median follow-up duration was 8.8 years. The range of motion of the shoulder and the glenoid inclination angle (GIA) were measured preoperatively and at the final visit. The range of motion of the shoulder and GIA improved at the final visit. There was a positive correlation between the maximum abduction angle of the upper limb and GIA at the final visit.

Quantitative assessment of the latarjet procedure for large glenoid defects by computed tomography: a coracoid graft can sufficiently restore the glenoid arc.

BACKGROUND: Coracoid transfer to a large glenoid defect is considered an excellent method to restore the surface area of the anteroinferior glenoid. However, there is little quantitative evidence supporting whether a coracoid graft can sufficiently restore the glenoid arc. PURPOSE: To assess whether the Latarjet procedure can sufficiently restore the surface area of the glenoid. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 44 patients who underwent a Latarjet operation for a large glenoid defect between February 2009 and July 2011 were enrolled in this study. Three-dimensional computed tomography was used to calculate the surface areas of the preoperative glenoid defect size and the reconstructed glenoid. Preoperative and postoperative clinical results also were assessed. RESULTS: At the last follow-up, the mean visual analog scale score for instability during motion improved significantly from 5.1 points (range, 3-10 points) preoperatively to 1.3 points (range, 0-4 points) (P<.001). The mean deficit in external rotation at the side, external rotation at 90° of abduction, and internal rotation to the posterior were 10°±20°, 7°±16°, and 1.9°±4°, respectively (P=.004, .022, and .009, respectively). The overall recurrence rate was 4.5% (2 of 44 shoulders). The mean preoperative glenoid defect size was 157±38 mm2 (range, 141-239 mm2; 25.3%±6% of the intact glenoid surface). The mean surface area of the coracoid graft used for reconstruction was 152±34 mm2 (range, 146-236 mm2; 24.8%±5% of the intact glenoid surface). After the Latarjet procedure, the mean surface area of the reconstructed glenoid was 706±32 mm2 (range, 639-749 mm2). Finally, postoperative glenoid defect size was 5±11 mm2 (range, 3-28 mm2; 1.5%±2% of the intact glenoid surface). CONCLUSION: The Latarjet procedure can provide satisfactory outcomes, including a low recurrence rate and reliable functional recovery. Defects at the anteroinferior glenoid were restored to nearly normal after coracoid transfer by use of the Latarjet procedure, which is an anatomically matched reconstruction.

Sprengel deformity: morphometric assessment and surgical treatment by the modified green procedure.

BACKGROUND: We evaluated the pathologic anatomy of the Sprengel deformity using radiographs, 3-dimensional computed tomography (3D-CT), and magnetic resonance imaging (MRI), and reviewed our results of the modified Green procedure. METHODS: Between 2002 and 2009, 23 scapulae in 22 patients were treated. The average age at the time of surgery was 3.4 years (range, 1.9 to 7.1 y). The outcome of surgery was assessed on the basis of changes in shoulder abduction and the radiographic findings using Cavendish classification, Rigault classification, scapular elevation, and medialization. Preoperative appearance was classified as grade III in 13 cases and grade IV in 10 cases according to the Cavendish classification, and as grade II in 4 cases and grade III in 19 cases according to the Rigault classification. Using 3D-CT, we assessed the height to width ratio on the scapular posterior view, the superior displacement ratio and rotational difference on the trunk posterior view, and the anterior curvature of the supraspinous portion on the scapular medial view. RESULTS: The average follow-up postoperative period was 4.4 years (range, 2.2 to 8.7 y). Postoperatively, the shoulder abduction improved well, with a mean improvement of 63 degrees. Improvement of at least 1 Cavendish grade and 1 Rigault grade was attained in all cases. On preoperative 3D-CT, the mean height to width ratio of the affected scapula was significantly smaller than that of the contralateral scapula. There was an inverse relationship between the superior displacement ratio and the rotational difference. Anterior curvature of the supraspinous portion was seen in all cases. Omovertebral bone was found in 20 cases. MRI identified unossified omovertebral cartilage that was not evident by radiographs or CT. Transient brachial plexus palsy occurred in 2 patients, both of whom recovered within 4 months. Postoperative scapula winging and unsightly scarring were seen in 3 and 8 cases, respectively. CONCLUSIONS: 3D-CT and MRI were helpful in evaluating the pathologic anatomy of the deformity and in planning the surgery. The modified Green procedure provided successful functional and cosmetic results. LEVEL OF EVIDENCE: Level IV.

An anatomic, computed tomographic assessment of the coracoid process with special reference to the congruent-arc latarjet procedure.

PURPOSE: The purpose of this study was to determine the dimensions of the coracoid and to compare the radius of curvature (ROC) of the intact glenoid to the ROC of the coracoid undersurface, as oriented in the congruent-arc Latarjet procedure. The ROC of the coracoid undersurface was also compared with various glenoid bone loss scenarios. METHODS: Thirty-four computed tomography-based 3-dimensional models of the shoulder were examined by use of commercially available software. The mean dimensions of the coracoid were determined, and the ROC was calculated for the coracoid undersurface, the intact glenoid, and 20%, 35%, and 50% anterior glenoid bone loss scenarios. Intra-rater and inter-rater statistics were calculated. RESULTS: The mean length, width, and thickness of the coracoid were 16.8 mm (SD, 2.5 mm), 15.0 mm (SD, 2.2 mm), and 10.5 mm (SD, 1.7 mm), respectively. The mean ROC values were 13.6 mm (SD, 3.4 mm) for the coracoid, 13.8 mm (SD, 2.1 mm) for the intact glenoid, 27.6 mm (SD, 5.3 mm) for 20% anterior glenoid bone loss, 30.5 mm (SD, 5.2 mm) for 35% bone loss, and 33.3 mm (SD, 5.2 mm) for 50% bone loss. The coracoid ROC was not significantly different from the intact glenoid (P = .75); however, it was significantly less (P < .01) when compared with all glenoid bone loss scenarios. Intra-rater reliability and inter-rater reliability were good or excellent. A coracoid oriented in the congruent-arc manner can reconstitute a significantly greater glenoid bone defect than a coracoid oriented in the classic manner (P < .001). CONCLUSIONS: This image-based anatomic study found that the ROC of the coracoid undersurface matches the ROC of the intact anterior glenoid articular margin. In conditions with anterior glenoid bony deficiency, the radii of curvature differ significantly at the graft-native glenoid interface; however, the coracoid graft placed in the congruent-arc manner reconstitutes the ROC of the missing anterior glenoid rim. In addition, orienting the coracoid in the congruent-arc manner can reconstitute a greater glenoid bone defect than a coracoid placed in the original manner as described by Latarjet. CLINICAL RELEVANCE: The congruent-arc Latarjet procedure, a modification of the original procedure, is truly congruent in relation to the intact anterior glenoid rim. In addition, the congruent-arc modification can reconstitute a greater glenoid bone defect when compared with the original Latarjet procedure.

Clavicle and scapula fracture problems: functional assessment and current treatment strategies.

Historically, nonsurgical treatment was recommended for both clavicle and scapula fractures. Good functional outcomes were reported with nonsurgical treatment, whereas surgical treatment had a high complication rate. Recent studies have shown that the functional outcomes of nonsurgically treated fractures may not be as acceptable as had been previously believed. These studies also support the surgical treatment of clavicle and scapula fractures in certain circumstances. Relative indications for surgical treatment of clavicle fractures include skin compromise, neurologic or vascular injury, open fractures, high-energy closed fractures with greater than 15 to 20 mm of shortening, fractures with 100% displacement, and fractures with comminution. Relative indications for the surgical treatment of scapula fractures include displaced acromion or coracoid process fractures (> 10 mm), displaced intra-articular glenoid fractures (> 5 mm), and those associated with humeral subluxation.

Functional laboratory assessment after oncologic shoulder joint resections.

A laboratory evaluation was undertaken to assess the shoulder range of motion and distal strength after oncologic resection and reconstruction involving the shoulder joint and to compare these functional parameters based on potentially important variables. Inclusion in the study was limited to 32 patients with bone tumors of the proximal humerus or scapula treated surgically by resection of the shoulder joint including the proximal humerus from 1976 through 1992. Active shoulder range of motion and isometric elbow extension and forearm supination strength are significantly less after surgery in patients with greater amounts of bony resection and with resection of the deltoid. Patients who had a modified Tikhoff-Linberg resection were able to achieve 10 degrees to 15 degrees greater shoulder motion in each direction than were patients who had the classic procedure including complete scapulectomy. However, elbow flexion and extension strength and forearm pronation strength were greater for the patients with the classic resection. Osteoarticular allografts as a reconstructive alternative provide as a group the best shoulder motion and overall distal upper extremity strength, but these reconstructions were performed only when the rotator cuff muscles and deltoid were able to be reconstructed. Diminishing elbow strength was seen with longer followup in the patients with osteoarticular reconstructions, corresponding temporally to subchondral collapse observed on radiographs. Range of shoulder motion except rotation was just as good for allograft vascularized fibular arthrodeses as for the osteoarticular allografts, but strength was significantly less with the arthrodeses.

[Tumorous space occupying lesions of the scapula. An analysis of preoperative assessment of invasion]. / Tumoröse Raumforderungen der Skapula. Eine Analyse zur präoperativen Dignitätsbeurteilung.

The radiographic and histological morphology of 38 tumors lesions of the scapula are analyzed. Osteochondromas (n = 12), chondrosarcomas (n = 7), plasmacytomas (n = 4) and Ewing's sarcomas (n = 3) were the most frequent neoplasms. The radiographically determined growth rates allowed an estimate of the dignity in all cases. Benign lesions were only observed in the first five decades of life, and were mostly located in the scapular blade. Most tumors found in the acromion and in the glenoid region and all lesions diagnosed in the 6th to the 8th decades of life were malignant. In 63.2% of cases correct diagnosis of the type of lesion present was possible on radiographic examination.