The subscapularis-sparing approach in humeral head replacement.

BACKGROUND: This report represents a prospective case series evaluating an open deltopectoral approach, both radiologically and clinically, without tenotomy or complete takedown of the subscapularis tendon insertion. We hypothesized that this novel technical approach would allow preservation of the upper tendon border, thus decreasing subscapularis repair failures and fatty infiltration while simultaneously allowing accelerated rehabilitation. METHODS: Fifty patients underwent humeral head replacement surgery through a subscapularis-sparing approach. In this approach, we take down only the inferior 30% to 50% of the subscapularis tendon, leaving the critical superior aspect of the tendon attached to the lesser tuberosity. Forty-three patients were included in the postoperative results (7 were lost to follow-up). Nineteen patients had a postoperative magnetic resonance imaging study, and 24 patients had ultrasound evaluation. Physical examination included belly-press and lift-off tests; follow-up included visual analog scale, American Shoulder and Elbow Surgeons, Constant, modified UCLA, Rowe, and Short Form 12 scores. RESULTS: All patients had a minimum 2-year follow-up. All patients had subscapularis strength equal to the opposite side as measured by lift-off, belly-press, and bear hug tests. Average postoperative scores all showed statistically significant improvement except for general health. All had an intact subscapularis tendon attachment as evaluated by either magnetic resonance imaging or ultrasound imaging. None had atrophy in the muscle belly. CONCLUSIONS: The subscapularis-sparing, minimally invasive approach to the glenohumeral joint provides adequate exposure to allow humeral head replacement. When the upper border of the subscapularis insertion is left intact, there is a decreased risk of postoperative failure (rupture or atrophy) of the subscapularis tendon.

Efficacy of Two Techniques in Anterior Cruciate Ligament Reconstruction.

The purpose of this study is to compare failure rate and functional outcome in young, active patients (< 25 years) with two-incision (rear-entry) versus transtibial (all-endoscopic) anterior cruciate ligament (ACL) reconstructions.Utilizing a computerized relational database (Access 2007, Microsoft Inc., Redmond, WA), 480 patients were identified that underwent ACL reconstruction, using a bone-patellar-tendon-bone autograft, by a single surgeon between January 2000 and December 2010 via a transtibial or two-incision technique. Totally, 377 (78.6%) of these patients were less than 25 years of age. Data for each patient were collected at their initial clinic visit, at the time of surgery, and at each follow-up clinic visit and entered into the computerized relational database. Overall, 274 patients (72.7%) underwent ACL reconstruction with a transtibial technique, and 103 patients (27.3%) underwent reconstruction with a two-incision technique. Failures were identified as a 2+ Lachman, 1+ or greater pivot shift, or a KT-1000 arthrometer difference of five or more.In patients < 25 years of age, there were 10 failures (9.7%) out of 103 patients undergoing a two-incision reconstruction and 28 failures (10.2%) out of 274 patients undergoing a transtibial reconstruction (p = 1.000). There was no statistical significance between the failure rate in the two different groups in regards to gender, meniscal tear, activity level, or any other factor that was analyzed.Our study showed no statistical difference between the two-incision technique and the transtibial technique for ACL reconstruction using bone-patellar-tendon-bone autograft with an overall 10.1% failure rate in young, active patients (< 25 years of age). The level of evidence is level IV.

Surgical Technique: Medial Ulnar Collateral Ligament Reconstruction Using Hamstring Allograft.

INTRODUCTION: In the overhead throwing athlete, medial ulnar collateral ligament reconstruction utilizing a hamstring allograft as an alternative to an autograft provides similar results without the donor site morbidity or potential complications of autograft harvest. STEP 1 MRI OR MRA AND PREOPERATIVE PLANNING: Obtain an MRI or MRA to determine the location and importance of the tear in the ligament. STEP 2 MEDIAL ELBOW DISSECTION AND IDENTIFICATION OF THE MEDIAL ULNAR COLLATERAL LIGAMENT: Position the elbow to allow access to the medial side, and expose the medial ulnar collateral ligament via a flexor-pronator split approach. STEP 3 PREPARATION OF HAMSTRING ALLOGRAFT: Prepare the non-irradiated hamstring allograft by placing lead Krackow stitches into each end, and if necessary suture it in the middle to help with passage through the bone tunnels. STEP 4 ULNAR-SIDED RECONSTRUCTION: Use a single-hole technique, inserting a Beath pin into the sublime tubercle to allow a single screw to fix the graft into the ulna, OR use a double-hole technique, making connecting drill holes under the sublime tubercle and passing the graft through the tunnels. STEP 5 HUMERAL-SIDED RECONSTRUCTION: Place a single drill hole into the center of the origin of the medial ulnar collateral ligament at the distal end of the medial epicondyle; place two connecting tunnels and shuttle the graft ends through these tunnels. STEP 6 GRAFT FIXATION AND LIGAMENT REPAIR: Tension the graft while the elbow is placed though a full arc of motion, suture the two limbs of the graft together, and suture the medial ulnar collateral ligament to the graft. STEP 7 CLOSURE: Irrigate the wound, repair the flexor-pronator fascia with absorbable suture, and perform a standard subcutaneous and skin closure. RESULTS: Medial ulnar collateral ligament reconstruction utilizing a hamstring allograft instead of an autograft has so far produced excellent results.IndicationsContraindicationsPitfalls & Challenges.

Surface Replacement Arthroplasty of the Humeral Head in Young, Active Patients: Midterm Results.

BACKGROUND: The treatment of glenohumeral arthritis in young, active patients remains controversial. Standard total shoulder arthroplasty in this patient group has not obtained the same satisfaction rate as in older patients. One surgical option that has emerged is humeral resurfacing. HYPOTHESIS: Humeral head surface replacement arthroplasty (SRA) would provide satisfactory clinical outcomes in active patients, allowing them to maintain their normal lifestyle without activity restrictions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 2004 to 2007, all consecutive surface replacement arthroplasties of the humerus performed at the authors' institution were identified and retrospectively reviewed, and 118 patients who underwent SRA during this time were identified. This study included patients younger than 60 years who wished to maintain an active lifestyle; 52 of the 118 patients met the inclusion criteria. University of California at Los Angeles (UCLA) shoulder scores and subjective shoulder value (SSV) scores were used to measure clinical outcomes at an average follow-up of 6 years (range, 4-8 years). Of the 52 patients meeting the inclusion criteria, 48 were contacted and examined for the study, with 4 patients lost to follow-up. RESULTS: The mean postoperative UCLA score was 28.03, with 1 patient requiring revision because of pain and glenoid wear. The mean SSV was 92% (range, 0%-100%), with 3 patients restricting their activity because of the shoulder. Forty-seven of the 48 contacted patients stated that, given the option, they would have the same surgery again. One patient required revision surgery because of pain. CONCLUSION: Surface replacement arthroplasty provided reasonable results in patients younger than 60 years with high activity demands with a low rate of revision at midterm follow-up.