A prospective randomized controlled trial comparing plating augmented with coracoclavicular fixation and hook plate fixation of displaced distal-third clavicle fractures.

BACKGROUND: Two popular methods used to treat distal-third clavicle fractures are the traditional hook plate and the anatomically contoured locking plate. No consensus exists on whether one method is more effective than the other. Therefore, the aim of this study was to compare the efficacy of a traditional hook plate with that of an anatomically contoured locking plate augmented with coracoclavicular fixation in the treatment of distal-third clavicle fractures. METHODS: Enrolled patients were randomly assigned to either the hook plate group (n = 13) or the locking plate group (n = 17). Follow-up assessments (clinical and radiologic) were performed at 6 and 12 months postoperatively. RESULTS: In both groups, union was achieved in 91% of cases at 6 months and 100% at 12 months. No differences in Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley shoulder scores were noted between the hook plate and locking plate groups at 12 months. From 6 to 12 months, DASH scores improved in the hook plate group (P = .007) and Constant-Murley shoulder scores tended to improve (P = .075). Surgical time was longer in the locking plate group than in the hook plate group (P < .001). CONCLUSION: Similar functional outcomes and union rates were achieved in both groups at 12 months postoperatively. However, the improvement in DASH scores in the hook plate group from 6 to 12 months suggests that patients treated with an anatomically contoured locking plate make a quicker recovery than patients treated with a hook plate.

Treating hoarding disorder with compassion-focused therapy: A pilot study examining treatment feasibility, acceptability, and exploring treatment effects.

OBJECTIVES: Hoarding disorder (HD) was recognized as a psychiatric disorder in 2013. Existing literature suggests room for improvement in its treatment. The current pilot study aimed to provide an initial evaluation on the potential of compassion-focused therapy (CFT) as an intervention for HD, with the primary aim being assessing its feasibility and acceptability, and the secondary being evaluating its effects. DESIGN: Both CFT and a second round of the current standard of treatment and cognitive behavioural therapy (CBT) were investigated in the current study as follow-up treatment options for individuals who had completed CBT but were still significantly symptomatic. METHODS: Forty eligible individuals were enrolled (20 in each treatment). Treatment feasibility and acceptability were assessed by quantitative and qualitative measures. To explore treatment effects, HD symptom severity, HD-related dysfunctions, and their underlying mechanisms were assessed pre-treatment and post-treatment. RESULTS: Retention rates were 72% for CFT and 37% for CBT. All participants and 79% of the participants rated CFT and CBT, respectively, as good or excellent. After receiving CFT as a follow-up treatment, HD symptom severity dropped below the cut-off point for clinically significant HD for 77% of the treatment completers, and 62% achieved clinically significant reduction in symptom severity. In contrast, after completing a second course of CBT, 23% had HD symptom severity dropped below the cut-off threshold, and 29% achieved clinically significant symptom reduction. CONCLUSIONS: The current study showed satisfactory feasibility and acceptability of CFT. Moreover, it also found promising effects of CFT in addressing hoarding-related mechanisms that may not have been sufficiently addressed by CBT. The results suggest promising potential of CFT as a treatment for HD. Further investigation on this intervention is needed. PRACTITIONER POINTS: CFT may be a promising treatment option, particularly for those who do not respond well to CBT. Improving emotion regulation and negative self-perception by applying CFT interventions may help relieve hoarding symptoms. Generalization of the findings should be applied with caution given the small convenience sample of the current study. Statistical comparison on treatment effect measures between CFT and CBT as follow-up treatments was not available due to small sample size. Therefore, the comparative conclusions based on this pilot study should be made with caution.

The 12-month analysis from Basal Cell Carcinoma Outcomes with LDE225 Treatment (BOLT): A phase II, randomized, double-blind study of sonidegib in patients with advanced basal cell carcinoma.

BACKGROUND: The hedgehog pathway inhibitor sonidegib demonstrated meaningful tumor shrinkage in more than 90% of patients with locally advanced basal cell carcinoma (BCC) or metastatic BCC in the BCC Outcomes with LDE225 Treatment study. OBJECTIVE: This report provides long-term follow-up data collected up to 12 months after the last patient was randomized. METHODS: In this multicenter, randomized, double-blind phase II study, patients were randomized 1:2 to sonidegib 200 or 800 mg. The primary end point was objective response rate assessed by central review. RESULTS: Objective response rates in the 200- and 800-mg arms were 57.6% and 43.8% in locally advanced BCC and 7.7% and 17.4% in metastatic BCC, respectively. Among the 94 patients with locally advanced BCC who responded, only 18 progressed or died and more than 50% had responses lasting longer than 6 months. In addition, 4 of 5 responders with metastatic BCC maintained an objective response. Grade 3/4 adverse events and those leading to discontinuation were less frequent with sonidegib 200 versus 800 mg (38.0% vs 59.3%; 27.8% vs 37.3%, respectively). LIMITATIONS: No placebo or comparator arms were used because sonidegib demonstrated efficacy in advanced BCC in a phase I study, and the hedgehog pathway inhibitor vismodegib was not yet approved. CONCLUSION: With longer follow-up, sonidegib demonstrated sustained tumor responses in patients with advanced BCC.

Risk of insufficient internal rotation after bilateral reverse shoulder arthroplasty: clinical and patient-reported outcome in 57 patients.

BACKGROUND: Bilateral reverse shoulder arthroplasty (RSA) is controversial because of potential rotational deficits impairing daily living activities. We assessed achievement of insufficient internal rotation (IR) and associated factors in bilateral RSA patients. METHODS: Fifty-seven staged bilateral RSA patients with a minimum of 1 year of follow-up after the second intervention were identified from our local monocentric register. Shoulder range of motion (including IR using the Apley scratch test), strength, and Constant and Shoulder Pain and Disability Index scores were assessed preoperatively and 6, 12, and 24 months postoperatively. RESULTS: Before surgery, both shoulders were similar regarding imaging parameters, but first operated shoulders tended to have poorer function. One year after the first RSA, 21% of patients had insufficient IR (not reaching the lumbosacral junction) compared with 33% after the second intervention (P = .180). At 2 years, 5% of patients had insufficient IR on both sides. Patients with insufficient IR on the second side at baseline (relative risk [RR], 1.8 [1.0-3.2]) and patients with insufficient IR 1 year after the first RSA (RR, 3.0 [1.6-5.6]) were more likely to have insufficient IR 1 year after the second RSA. Constant and Shoulder Pain and Disability Index scores and abduction of the second side were significantly worse 1 year after the second RSA (P ≤ .047); at 2 years, there were no differences in functional outcome between shoulders. CONCLUSION: A minority of bilateral RSA patients did not achieve sufficient IR on at least 1 side. Staged surgery is justified, particularly when the outcome of the initial operation is satisfactory.

Readmission after shoulder arthroplasty.

BACKGROUND: Health care payers, including the federal government, increasingly base reimbursement on quality. Payers consider readmission rates after total joint arthroplasty an indicator of quality. The Patient Protection and Affordable Care Act contains provisions that preclude payment of hospital cost associated with joint arthroplasty readmissions occurring within 30 days of discharge. This study evaluates the readmission rates and the incidence of "never events" after inpatient shoulder arthroplasty procedures. METHODS: A retrospective view of all shoulder arthroplasty was performed from 2005 to 2011, with specific emphasis on the readmission rate 30, 60, and 90 days after the procedure. The incidence of never events as defined by the Centers for Medicare and Medicaid Services was also analyzed. RESULTS: During the study period, 680 shoulder arthroplasty procedures were performed. Overall readmission rate was 5.9%. For hemiarthroplasty (HA), total shoulder arthroplasty (TSA), and reverse total shoulder arthroplasty (RTSA), 90-day readmission rates were 8.8%, 4.5%, and 6.6%, respectively. Readmission rates within 30 days of admission were significantly more common for HA and RTSA compared with readmission rates after 30 days. There was a 1.0% incidence of never events, and the incidence associated with each of the 3 arthroplastic procedures did not differ significantly. CONCLUSION: Readmission within the first 90 days after shoulder arthroplasty occurred in 5.9% of patients. There was a 1% incidence of never events. In addition, most readmissions after HA and RTSA occurred within 30 days of discharge. As health care expenditures become more closely scrutinized, readmission rates after shoulder arthroplasty will become increasingly important.

Wound complications after distal humerus fracture fixation: incidence, risk factors, and outcome.

BACKGROUND: This study set out to accurately determine the incidence of wound complications after distal humerus fracture fixation, to assess risk factors, and to determine their implications on outcome. METHODS: Eighty-nine distal humerus fractures (mean patient age, 58 years) were treated with internal fixation at an average of 4 days after injury. Mean follow-up time was 15 months (range, 6-72 months). Twenty-nine (33%) fractures were open. Medical records and radiographs were reviewed to determine wound complications. Logistic regression analysis was carried out to determine associated risk factors. RESULTS: Fourteen patients (15.7%) developed a major wound complication requiring on average 2.5 (range, 1-6) additional surgical procedures. Six patients required plastic surgical soft tissue coverage. All 14 fractures complicated by wound problems united. The final mean range of motion in the major wound complication group was 100° (range, 65°-130°), compared with 100° (range, 10°-140°) in those with no or minor wound problems. Grade III open fractures and the use of a plate to stabilize the olecranon osteotomy were identified as significant risk factors for development of major wound complications. CONCLUSIONS: The incidence of major wound complications after fixation of distal humerus fractures is substantial. The presence of a grade III open fracture and the use of an olecranon osteotomy stabilized with a plate are significant risk factors for major wound complications. Fracture healing rates and functional elbow range of motion do not appear to be affected by major wound complications when they are handled with proper soft tissue coverage techniques.

Elbow arthroscopy: early complications and associated risk factors.

BACKGROUND: Elbow arthroscopy is increasingly used to treat complex pathology. The purpose of this study was to investigate early complication rates after elbow arthroscopy and identify risk factors for adverse events. METHODS: Consecutive elbow arthroscopies performed during a 13-year period were reviewed, identifying early perioperative complications. Major complications included deep infection, permanent nerve injury, or complications requiring additional anesthesia. Minor complications included superficial wound complications and transient nerve palsies. Complications were compared with a surgical complexity scale based on the procedure performed, the number of arthroscopic portals, and tourniquet time. RESULTS: Of 417 procedures, there were 37 minor (8.9%) and 20 major (4.8%) complications. The rates of superficial and deep infections were 6.7% and 2.2%, respectively. Major complications included 9 deep infections, 6 cases of heterotopic ossification requiring further surgery, and 4 manipulations under anesthesia. There were 7 transient sensory nerve complications, and no motor deficits. No differences in complication rates were seen between low-, moderate-, and high-complexity (10.2%, 16.3% and 14.4%, respectively) cases. Intraoperative steroid injections were strongly associated with postoperative superficial (14.1% vs 2.0%) and deep infection (4.9% vs 0.4%) in elbows receiving vs those not receiving steroid (P < .0001). CONCLUSIONS: Complications of elbow arthroscopy are seen in approximately 14% of cases. Most complications are minor, not affecting clinical outcome. Major complications occur in 5% of cases, often requiring repeat surgery. Intraoperative postsurgical steroid injections are associated with increased risk of perioperative infections. Case complexity does not appear to affect the rate of complications with modern surgical techniques.

Reconstruction of the chronic anterior unstable sternoclavicular joint using a tendon autograft: medium-term to long-term follow-up results.

BACKGROUND: Chronic symptomatic anterior sternoclavicular (SC) instability is a rare condition with sparse treatment options. Owing to the rarity of the condition and the potential risk of fatal complications, only a few reports on treatment of this condition have been published. We evaluated a prospective series of patients with chronic anterior SC instability who underwent minimally open reconstruction with an autologous tendon graft. METHODS: From 2002 to 2010, 32 consecutive patients underwent minimally open SC ligament reconstruction using a tendon autograft. A palmaris longus was used in 7 patients and a gracilis tendon autograft was used in 25. All patients with at least 2 years of follow-up were reviewed. Five were lost to follow-up. The remaining 27 patients (84.4%) were a median age of 35 years (range, 11-61 years) at surgery. Patients were evaluated with the Western Ontario Shoulder Instability (WOSI) score preoperatively and at follow-up at a median 54 months (range, 24-120 months) postoperatively. RESULTS: The total WOSI score improved from a median of 44% (range 6%-62%) preoperatively to 75% (range, 13%-93%) at follow-up (P = .0001). Two failures (7.4%) occurred; after revision, both patients remained stable. After the operation, 17 of 25 patients (68%) complained of donor site morbidity, and 10 (40%) still had some discomfort at follow-up. No infections or local vascular complications occurred. CONCLUSIONS: Miniopen SC joint reconstruction using a tendon autograft results in prolonged improvement in shoulder function in most patients with symptomatic anterior SC instability.

Aseptic loosening rate of the humeral stem in the Coonrad-Morrey total elbow arthroplasty. Does size matter?

BACKGROUND: Aseptic implant loosening is one of the most common complications leading to revision surgery in total elbow arthroplasty. Different humeral stem lengths are available with varying designs. In general, the decision of which stem length to use depends on the surgical diagnosis or simply the surgeon preference. Often, the longer stem is used for post-traumatic or revision cases while for rheumatoid patients the shorter stem is preferred. There are no data in the literature to favor one humeral stem size over the other according to the diagnosis. METHODS: We analyzed the total elbow joint database of the Coonrad-Morrey design at our institution for aseptic loosening leading to revision and compared the revision rate and the survival of the 4- and 6-inch humeral stems. RESULTS: Overall, revision for aseptic humeral loosening is infrequent and occurred in only 16 of 711 total elbow arthroplasties during a mean follow-up of 88 months. There was no significant difference in the revision rate between the 2 stem lengths (1.9% for the 4-inch stems and 2.6% for the 6-inch stem). CONCLUSION: Revision rate was correlated to the surgical diagnosis and was significantly higher for post-traumatic patients than for rheumatoid patients (5.1% vs 0.66%, P < .001). Of interest, and possibly not surprising, the mean time to revision was shorter for the 4-inch stems than it was for the 6-inch stems (37 vs 95 months, P = .034).

Anatomic study of the flexor carpi ulnaris muscle and its application to soft tissue coverage of the elbow with clinical correlation.

BACKGROUND: The posterior elbow is prone to soft tissue loss that may require reconstructive methods for wound healing to be achieved. The flexor carpi ulnaris (FCU) muscle has been described for coverage in case reports and small series. Previous studies give conflicting anatomic findings about the dominant vascular pedicle for the FCU. METHODS: Twenty-five cadaveric specimens were dissected. Pedicle location, number, and distance from the medial epicondyle were recorded along with the extent of posterior elbow coverage. Chart review was conducted during a 4-year period. Eight patients who underwent FCU rotational flap coverage were identified. Those flaps relied entirely on a single proximal pedicle. RESULTS: The vascular pedicles from the ulnar artery or recurrent ulnar artery were identified in 24 of 25 specimens. The average distance from the tip of the medial epicondyle to the first pedicle was 5.7 cm (range, 3 to 10 cm). The length of muscle coverage proximal to the olecranon tip averaged 9.3 cm. The clinical follow-up of 7 patients requiring FCU rotational flaps for coverage of the posterior elbow showed that all flaps survived and provided adequate coverage for the defect. CONCLUSIONS: The FCU rotational pedicle flap provides predictable coverage of small to medium-sized defects about the posterior elbow. Although it is relatively consistent, the proximal vascular pedicle does demonstrate some variability, which should be considered in planning surgery. The consistent distal extent of the FCU muscle belly provides wider proximal coverage of defects.

Treatment of osteoid osteoma of the elbow by radiofrequency thermal ablation.

BACKGROUND: This article presents the experience at the Rizzoli Orthopaedic Institute in the treatment of intracapsular osteoid osteoma (OO) of the elbow by computed tomography-guided percutaneous radiofrequency thermal ablation (RFA). MATERIALS AND METHODS: Our team performed more than 800 RFA procedures to treat OO up to 2010. In 27 cases, the lesion site was the articular area of the elbow (humerus in 13 cases, ulna in 13, and radius in 1). These patients were reviewed and assessed for eradication rate, incidence of complications, and functional results measured by the Mayo Elbow Performance Score. The outcome was evaluated after a mean follow-up period of 67.4 ± 35.3 months (range, 24-128 months). RESULTS: The mean duration of symptoms at the time of diagnosis was 31.0 ± 19.8 months (range, 5-72 months). All patients complained about pain, and in 24 of 27 cases (88.8%), the joint function was significantly impaired by the presence of OO (pretreatment score, 54.8). After RFA, the Mayo Elbow Performance Score improved by a mean of 37.7 ± 14.8 points, with 25 of 27 patients (92.5%) scoring 90 to 100 points at final follow-up. OO recurred in only 1 patient (3.7%), 5 months after the procedure. However, this was successfully retreated by RFA. No adverse effects were observed, and all patients were free of disease at the final follow-up. DISCUSSION: The RFA procedure can be technically challenging in difficult sites such as the elbow joint. The low invasiveness of RFA compared with traditional surgery allows excellent functional recovery. RFA of elbow OO is effective and safe, and it should be considered the first-choice treatment for this disease.

Surgical fixation of extra-articular distal humerus fractures with a posterolateral plate through a triceps-reflecting technique.

BACKGROUND: Surgical management of extra-articular distal humerus fractures results in predictable fracture alignment. Open reduction and internal fixation also decrease the soft tissue complications and frequent follow-up required with functional bracing. A triceps-reflecting posterior approach provides excellent exposure to the humerus and minimizes trauma to the triceps. An anatomically precontoured plate on the posterolateral surface of the humerus provides stable fixation of these injuries and is placed directly through the interval developed by the triceps-reflecting approach. METHODS: We retrospectively reviewed the trauma databases at 2 level I academic trauma institutions during a 5-year period for all patients with an extra-articular distal humerus fracture treated with a triceps-reflecting approach and an anatomically precontoured posterolateral distal humerus plate. Patient and fracture characteristics were recorded, as were QuickDASH functional scores and visual analog scale scores for pain, function, and quality of life. RESULTS: Forty patients were eligible for our study. Average follow-up was 88 weeks. Thirty-eight (95%) patients went on to union. Seven (20%) patients required a secondary procedure. The average QuickDASH score was 17.5 (range, 2.6-56.8). The average visual analog scale scores were 1.9 (range, 0-7) for pain, 2.3 (range, 0-8) for function, and 1.6 (range, 0-5) for quality of life. Thirty-five (87.5%) patients reported satisfaction with the outcome of their surgery. DISCUSSION: Surgical fixation of extra-articular distal humerus fractures through a triceps-reflecting approach with an anatomically precontoured posterolateral distal humerus plate results in predictable osseous union and overall excellent functional results for patients with this injury.

The incidence and risk factors for blood transfusion in revision shoulder arthroplasty: our institution's experience and review of the literature.

HYPOTHESIS: The purposes of this study were to determine the incidence of blood transfusion after revision shoulder arthroplasty and to assess risk factors associated with an increased risk of transfusion. MATERIALS AND METHODS: Between 1994 and 2008, 566 consecutive revision shoulder procedures were performed at our institution, which formed the basis of this study. The patient's age, sex, body mass index, comorbidities, preoperative and postoperative hemoglobin level, details of the surgery, operative time, and transfusion details were documented retrospectively from medical records. RESULTS: Overall, 11.3% of patients (64 of 566) required a transfusion. An increased transfusion rate was associated with age (odds ratio [OR] per 10 years, 1.5 [95% confidence interval (CI), 1.2 to 2.0]; P = .002), operative time (≤ 5 hours vs >5 hours) (OR, 3.3 [95% CI, 1.9 to 5.8]; P < .001), diabetes (OR, 2.3 [95% CI, 1.2 to 4.4]; P = .01), and cardiac disease (OR, 2.7 [95% CI, 1.5 to 5.0]; P < .001). There were significant associations between preoperative hemoglobin level (OR, 0.4 per 1 point [95% CI, 0.3 to 0.5]; P < .001) and a decreased odds of transfusion. The type of surgery (surgery on humeral component) also had an impact on the need for transfusion (P < .001). CONCLUSIONS: Older age, low preoperative hemoglobin level, increased operative time, diabetes, presence of cardiac disease, and type of revision surgery are associated with higher postoperative transfusion rates. These factors should be taken into consideration to more accurately predict the need for transfusion and modify preoperative blood-ordering protocols.

Medial scapular muscle detachment: clinical presentation and surgical treatment.

BACKGROUND: This study describes the clinical presentation and preliminary outcomes in a cohort of patients treated for detachment of the medial scapular stabilizing muscles. METHODS AND METHODS: The study included 72 patients who underwent reattachment of the lower trapezius and rhomboid muscles. Patients presented with a history of a high level of medial scapular border pain during activity and inability to perform overhead or forward flexion activities. Clinical examination demonstrated palpable tenderness along the medial scapular border, palpable defect along the medial border muscles, scapular dyskinesis, decreased scapular/rotator cuff strength, and modification of symptoms by manual scapular repositioning. Surgical exploration revealed detachment of the lower trapezius muscle or rhomboid muscles, requiring muscle reattachment to the scapula. Clinical outcomes were measured by the American Shoulder and Elbow Surgeons (ASES) self-report form, with comparisons made between the overall scores and subcomponents obtained at initial evaluation, discharge from active care, and postdischarge follow-up. RESULTS: Time from injury to treatment averaged 52 months, and time from surgery to discharge was 7.4 months. ASES scores significantly improved from initial evaluation (39 ± 16) to discharge (63 ± 21) (P < .001). At medium-term follow-up (n = 23), ASES scores significantly improved from initial evaluation (38 ± 14) to discharge (69 ± 20) (P < .001). CONCLUSIONS: Scapular muscle detachment appears to be a clinically identifiable syndrome with a homogeneous set of history and physical findings. Surgical treatment can significantly reduce pain and improve functional outcomes.

Durability of partial humeral head resurfacing.

BACKGROUND: Partial humeral head resurfacing arthroplasty uses a stemless device, which conserves bone and restores normal anatomy. We hypothesized that this does not offer a reasonable alternative to full resurfacing or total shoulder arthroplasty. METHODS: We performed a retrospective study of 39 shoulders with focal chondral defects of the humeral head treated with partial resurfacing arthroplasty. A minimum of 2 years' follow-up was reported, unless failure and operative intervention superseded this duration. The mean follow-up period was 51.3 months. The mean age was 45.6 years (range, 27-76 years). Preoperative and postoperative evaluation included history, physical examination, radiographs, and clinical scoring with the American Shoulder and Elbow Surgeons Shoulder Score Index and Subjective Shoulder Value. RESULTS: Of the 39 shoulders, 25 (64.1%) showed functional improvement and decreased pain. Significant mean improvements were observed in forward flexion (121° to 152°, P = .002), external rotation (37° to 58°, P = .0003), mean Subjective Shoulder Value (31% to 74%, P < .0001), and ASES score (29 to 70, P < .0001). However, at a mean of 26.6 months' follow-up, the failure group included 6 patients (15.3%) who underwent revision and another 4 (10.2%) who were recommended to undergo revision. Patients with no prior or concomitant procedures were rare (n = 5) but had the most reliable outcomes with partial resurfacing, with no failures in that group. Of the 24 patients with prior procedures, 5 had undergone revision, and the clinical outcome scores for the remaining patients were consistently lower than those seen in patients without prior procedures. CONCLUSION: Concomitant pathology and prior or concomitant surgical procedures potentially impair the outcome of the resurfacing procedure and could be a contraindication. Long-term success remains guarded with this treatment modality, especially in patients whose chondral injury is not an isolated finding.

Hemiarthroplasty of the distal humerus for acute and chronic complex intra-articular injuries.

BACKGROUND: Comminuted intra-articular distal humeral fractures represent a challenging upper extremity injury. This study reviews clinical and radiographic results in patients with distal humeral hemiarthroplasty (DHH). METHODS: DHH with the Latitude prosthesis (Tornier, Saint-Ismier, France) was performed in 8 patients (mean age, 64 years; age range, 33-75 years) for unreconstructible fractures of the distal humerus or salvage of failed internal fixation. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons elbow instrument; Mayo Elbow Performance Index; and Disabilities of the Arm, Shoulder and Hand questionnaire at a mean of 36 months. Radiologic assessment included radiographs and computed tomography to evaluate olecranon wear and densitometry (dual-energy x-ray absorptiometry). Range of motion, pain, and elbow satisfaction were recorded, and descriptive statistics were used for analysis. RESULTS: Seven patients were available to participate in the follow-up examination. Acute cases (5 patients) scored better than salvage cases (2 patients) on the Mayo Elbow Performance Score (80 points [range, 67-95 points] and 65 points [range, 50-80 points], respectively) and Disabilities of the Arm, Shoulder and Hand score (31 points [range, 2.5-68 points] and 39 points [range, 17-62 points], respectively). The mean arc of elbow flexion and extension was 96° (range, 70°-130°), with mean flexion of 120° (range, 90°-135°) and a mean extension loss of 19° (range, 5°-30°). The mean arc of forearm rotation was 160° (range, 140°-180°). Reoperation was required in 4 patients because of painful retained hardware. Five patients reported pain with activities of daily living. CONCLUSION: DHH should be used with caution until such time as longer-term outcome studies are able to show the efficacy of this procedure.

The outcome of scapulothoracic arthrodesis using cerclage wires, plates, and allograft for facioscapulohumeral dystrophy.

BACKGROUND: Scapulothoracic arthrodesis is a recognized treatment for impaired shoulder function in patients with facioscapulohumeral dystrophy (FSHD) and is traditionally performed with autograft. The purpose of the study was to report our experience with scapulothoracic arthrodesis in patients with FSHD using allograft, rather than autograft, with particular respect to the effect of fusion on preoperative and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores; forced vital capacity (FVC); and complications. MATERIALS AND METHODS: The early results of 14 consecutive scapulothoracic arthrodeses in FSHD patients with cerclage wires, plates, and allograft (fresh-frozen femoral heads) are reported. DASH scores were recorded preoperatively and 6 months postoperatively. Preoperative and 6-month FVCs were compared. The surgical technique is described. RESULTS: Eleven patients underwent 14 fusions. The mean follow-up period was 29 months (range, 6-50 months). Forward flexion improved from 70° to 115° (P = .001) and abduction from 68° to 109° (P = .007). The DASH score improved from 48 points to 34 points (P = .005). FVC decreased from 98% to 92% of predicted (P = .021), although this was not clinically significant. One patient required revision for nonunion, and metalwork was removed in 5 scapulae. A postoperative chest infection developed in 1 patient and a pleural effusion in another. One brachial plexus palsy occurred, which had almost completely resolved by 27 months postoperatively. CONCLUSION: Scapulothoracic arthrodesis can be performed successfully with allograft. The nonunion and complication rates are similar to those in the existing literature. A small decrease in FVC does occur but not to a clinically significant level.

Reverse total shoulder arthroplasty in patients of varying body mass index.

BACKGROUND: Body mass index (BMI) is an independent predictor of complications after hip and knee arthroplasty. Whether similar trends apply to patients undergoing reverse total shoulder arthroplasty (RTSA) is unknown. METHODS: A retrospective review of primary RTSAs with a minimum 90-day follow-up were included. Complications were classified as major or minor and medical or surgical. Patients were classified into 3 groups: normal BMI (BMI <25 kg/m(2)), overweight or mildly obese (BMI 25-35 kg/m(2)), and moderately or severely obese (BMI >35 kg/m(2)). RESULTS: Of the 119 patients met our inclusion criteria, 30 (25%) had a BMI of less than 25 kg/m(2); 65 (55%) had a BMI of 25 to 35 kg/m(2), and 24 (20%) had BMI exceeding 35 kg/m(2). Complications occurred in 30 patients (25%), comprising major in 11 (9%), minor in 19 (16%), surgical in 21 (18%), and medical in 14 (12%). The most common surgical complications were acute blood loss anemia requiring transfusion (8.4%) and dislocation (4.2%). The most common medical complications were atelectasis (2.5%) and acute renal insufficiency (2.5%). Patients with a BMI exceeding 35 kg/m(2) had a significantly higher overall complication rate (P < .05) and intraoperative blood loss (P = .05) than the other groups. Patients with BMI of less than 25 kg/m(2) had a greater overall complication rate than those with a BMI of 25 to 35 kg/m(2) (P < .05). Multivariate regression analysis demonstrated BMI was the only significant determinant of overall complication rates and medical complication rates (P < .05). CONCLUSION: Patients with a BMI exceeding 35 kg/m(2) (severely obese) or a BMI of less than 25 kg/m(2) have higher rates of complication after RTSA.

Characteristics of small to medium-sized rotator cuff tears with and without disruption of the anterior supraspinatus tendon.

BACKGROUND: The purpose of this study was to examine the baseline function and results of arthroscopic cuff repair in shoulders with small and medium-sized full-thickness cuff tears with complete supraspinatus disruption compared with those with an intact anterior supraspinatus tendon. METHODS: The study evaluated 112 subjects with small and medium-sized cuff tears. Subjects were grouped according to anterior supraspinatus integrity (83 shoulders intact, group 1; and 29 shoulders with anterior supraspinatus tendon disruption, group 2). Functional assessments included visual analogue scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test score, and Constant score. Repair integrity was assessed by ultrasound examination. RESULTS: Group 2 shoulders had greater mean tear width, length, and area (P < .0001) and greater supraspinatus muscle degenerative changes (P < .0001) compared with shoulders with an intact anterior supraspinatus tendon. There were no differences in demographics or baseline function (ASES score: 45 group 1 vs 46 group 2, P = .79; Constant score: 56 group 1 vs 52 group 2, P = .29) before surgery. There were no differences in any functional parameter (ASES score: 92 group 1 vs 93 group 2, P = .71; Constant score: 84 group 1 vs 85 group 2, P = .84) after surgery. There was no difference in tendon healing rates (93% group 1 vs 86% group 2; P = .26). CONCLUSIONS: In the setting of painful small and medium-sized rotator cuff tears, disruption of the anterior supraspinatus tendon was associated with greater tear size and more advanced supraspinatus muscle degeneration. However, anterior supraspinatus tendon integrity had no influence on the clinical presentation or the functional and structural results of cuff repair surgery.

Shoulder arthroplasty for osteoarthritis secondary to glenoid dysplasia: an update.

BACKGROUND: Glenoid component fixation is an issue in shoulder arthroplasty for glenoid dysplasia with osteoarthritis because of the small amount of bone available. In 2002, we described 6 patients (7 shoulders) undergoing shoulder arthroplasty for this condition. This report expands that experience to further understand the role of anatomic shoulder arthroplasty (both hemiarthroplasty and total shoulder arthroplasty), to outline results, and to identify complications and reoperations-all to better understand whether other treatment options need to be developed and explored. Our hypothesis is that treatment of this problem with anatomic arthroplasty is not ideal. METHODS: Between 1980 and 2008, 20 patients (22 shoulders) underwent anatomic shoulder arthroplasty for treatment of osteoarthritis secondary to glenoid dysplasia. There were 8 hemiarthroplasties and 14 total shoulder arthroplasties. Average follow-up was 6 years (range, 0.4 to 23.1 years). RESULTS: Pain was relieved in 4 of 8 shoulders undergoing hemiarthroplasty and in 10 of 14 shoulders undergoing total arthroplasty. Mean active elevation improved from 96° to 125°, and external rotation improved from 19° to 42°. Motion improvements were similar for hemiarthroplasty and total shoulder arthroplasty. Four shoulders having hemiarthroplasty underwent revision surgery because of painful glenoid arthrosis. Two shoulders with total arthroplasty underwent revision for infection, and 3 underwent revision for glenoid component issues. CONCLUSION: Favorable results can be obtained with the use of anatomic implants in the treatment of glenoid dysplasia. However, continuing subluxation, glenoid arthrosis, and glenoid component problems necessitating revision surgery are frequent. Alternative treatment methods should be considered.