Subscapularis tendon tear detection using axial internal rotation MRI: semiquantitative and quantitative analysis.

Background: Magnetic resonance image (MRI) of the subscapularis tendon plays an important role in preoperative planning. This retrospective study aimed to evaluate the diagnostic value and quantitative measurement of an additional internal rotation sequence in the detection of partial subscapularis tendon tears. Methods: The study included 76 patients who underwent arthroscopy and magnetic resonance (MR) shoulder between January 2018 to December 2019. Three different sets of images were evaluated in each case to determine the diagnostic value in the detection of partial subscapularis tendon tears including Set 1: standard axial fat-suppressed proton density (PD/FS) image and sagittal fat-suppressed T2 weight image (T2W/FS) images, Set 2: standard axial PD/FS and internal rotation PD/FS images, and Set 3: standard axial PD/FS, sagittal T2W/FS and axial internal rotation PD/FS images. Subscapularis tendon tear was diagnosed by arthroscopy and patients with or without tears were grouped. The coracohumoral distance (CHD), coracoglenoid angle (CGA), coracohumeral angle (CHA), CHD difference and CHD ratio were evaluated and compared between groups using univariate and multivariate analysis. The interreader agreement was assessed. The cut-off point for the prediction of subscapularis tears was calculated. Results: Twenty-nine shoulders revealed partial subscapularis tendon tears (29/76, 38.2%). Imaging Set 3 provided the highest sensitivity and accuracy {79-83% [confidence interval (CI): 0.60-0.95], 75-76% (CI: 0.63-0.85)}, compared to image Set 2 [31-58% (CI: 0.15-0.76), 67-68% (CI: 0.55-0.79)] and Set 1 [17-21% (CI: 0.06-0.40], 61-66% (CI: 0.54-0.76)], and a moderate level of interobserver agreement (Kappa =0.55). Axial CHD [odd ratio (OR) =1.48, P=0.044], internal rotate CHD (OR =0.68, P=0.02), CHD difference (OR =2.58, P<0.001), and CHD ratio (OR =1.34, P<0.001) were associated with subscapularis tears. A CHD difference and CHD ratio of more than 0.04 mm and 1.01 achieved a 90% sensitivity and 72% specificity, both. Conclusions: Internal rotation during MRI can increase diagnostic accuracy for subscapularis tendon partial tears. The CHD differences and CHD ratio are useful parameters to indicate subscapularis tears. This technique may improve preoperative management and reduce the consequences of delayed diagnosis and treatment.

Scapular dyskinesis after treatment of proximal humerus fracture, a 3-dimensional motion analysis and clinical outcomes.

BACKGROUND: The alteration of scapular kinematics can predispose patients to shoulder pathologies and dysfunction. Previous literature has associated various types of shoulder injuries with scapular dyskinesis, but there are limited studies regarding the effect that proximal humeral fractures (PHFs) have on scapular dyskinesis. This study aims to determine the change in scapulohumeral rhythm following treatment of a proximal humerus fracture as well as differences in shoulder motion and functional outcomes among patients who presented with or without scapular dyskinesis. We hypothesized that differences in scapular kinematics would be present following treatment of a proximal humerus fracture, and patients who presented with scapular dyskinesis would subsequently have inferior functional outcome scores. METHODS: Patients treated for a proximal humerus fracture from May 2018 to March 2021 were recruited for this study. The scapulohumeral rhythm and global shoulder motion were determined using a 3-dimensional motion analysis (3DMA) and the scapular dyskinesis test. Functional outcomes were then compared among patients with or without scapular dyskinesis, including the SICK (scapular malposition, inferomedial border prominence, coracoid pain and malposition, and dyskinesis of scapular movement) Scapula Rating Scale, the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the visual analog scale (VAS) for pain, and the EuroQol-5 Dimension 5-Level questionnaire (EQ-5D-5L). RESULTS: Twenty patients were included in this study with a mean age of 62.9 ± 11.8 years and follow-up time of 1.8 ± 0.2 years. Surgical fixation was performed in 9 of the patients (45%). Scapular dyskinesis was present in 50% of patients (n = 10). There was a significant increase in scapular protraction on the affected side of patients with scapular dyskinesis during abduction of the shoulder (P = .037). Additionally, patients with scapular dyskinesis demonstrated worse SICK scapula scores (2.4 ± 0.5 vs. 1.0 ± 0.4, P = .024) compared to those without scapular dyskinesis. The other functional outcome scores (ASES, VAS pain scores, and EQ-5D-5L) showed no significant differences among the 2 groups (P = .848, .713, and .268, respectively). CONCLUSIONS: Scapular dyskinesis affects a significant number of patients following treatment of their PHFs. Patients presenting with scapular dyskinesis exhibit inferior SICK scapula scores and have more scapular protraction during shoulder abduction compared to patients without scapular dyskinesis.

A new classification for combined greater tuberosity fracture and anterior shoulder dislocation: A study of fracture configurations and displacement after reduction.

OBJECTIVE: The aim of this study was to propose a new classification of combined greater tuberosity (GT) fractures and anterior shoulder dislocation and studied the degree of displacement, functional outcomes, and need for additional surgery after reduction. METHODS: A cross-sectional study was conducted. We evaluated radiographs of patients treated for combined GT fractures and anterior shoulder dislocation. Three morphologies were proposed; type 1 (a small avulsion), type 2 (GT fractures without articular head involvement), and type 3 (GT associated with articular head fractures). Two orthopedic surgeons independently measured all radiographs and classified fractures into three types. Patients were interviewed by telephone to assess functional outcomes (the simple shoulder test (SST) and EQ-5D-5L), and additional shoulder surgery was also performed. RESULTS: There were 52 eligible patients; 32 were male (61.5%) and the mean age was 57.3 · 17.1 years. Most cases were low-energy injuries (61.5%). Of all the cases, 32.7% were type I, 59.6% type II, and 7.7% type III cases. There were differences in the degree of displacement in each group at pre, post-reduction (both horizontal and vertical planes) and at two weeks post-reduction for HD (p < 0.05). Type III had more displacement than type I at pre- and post-reduction with a P value of less than 0.05. Type III also had higher rates of displacement than type II at post-reduction and at two-week postreduction (vertical plane). The intra and inter-rater reliabilities of measurement (ICC > 0.8) were in good to excellent agreement with the kappa value (>0.9). Three out of 52 cases (5.8%) required an additional surgery after closed reduction. Patients had good functional outcomes (SST score of 8) with an excellent utility index of EQ-5D-5L (0.9). CONCLUSION: This new classification exhibited good-to-excellent intra-and inter-rater reliabilities, with an ability to determine injury type. Type III seems to be linked to higher risk of fracture displacement and may require additional surgery. LEVEL OF EVIDENCE: Level IV, Diagnostic Study.

Cutoff Value for the Patient Acceptable Symptom State of the Thai IKDC Subjective Knee Form in Patients After Primary ACL Reconstruction.

Background: The Patient Acceptable Symptom State (PASS) cutoff is the value on a patient-reported outcome measure beyond which patients consider themselves to be "feeling well." There are limited data regarding the PASS threshold for non-English versions of the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF). Purpose: To establish the PASS cutoff for the Thai version of the IKDC-SKF for patients undergoing primary anterior cruciate ligament reconstruction (ACLR) and to identify factors to achieve PASS after surgery. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Included in this study were patients aged 18 to 50 years who had undergone primary unilateral ACLR between January 2016 and February 2020. After enrollment, patients completed the Thai IKDC-SKF and answered the anchor question for determining the PASS. Results: Questionnaires were sent to 321 patients, of whom 173 (53.9%) responded. The vast majority (156 patients; 90.2%) considered themselves to have achieved the PASS. This group of patients had significantly higher IKDC scores than did those who did not have an acceptable symptom state (79.6 ± 14.2 vs 60.7 ± 16.5; P < .001). The receiver operating characteristic curve of the IKDC score for predicting the PASS had an area under the curve of 0.82 (95% CI, 0.72-0.91). The optimum PASS cutoff of the Thai IKDC-SKF was a score of 74.2 (sensitivity, 0.72; specificity, 0.82). Factors that provided favorable odds for achieving the PASS were the use of a hamstring tendon autograft (odds ratio, 4.1; 95% CI, 1.5-20.6) and the absence of a patellofemoral chondral lesion (odds ratio, 3.8; 95% CI, 1.03-14.1). Conclusion: For patients undergoing ACLR, the cutoff for the PASS of the Thai version of the IKDC-SKF was a score of 74.2. Two surgery-related factors provided favorable odds for achieving the PASS: the use of a hamstring tendon autograft and the absence of a patellofemoral chondral lesion.

Arthroscopic Treatment of a Large Mass of the Medial Side of the Leg Caused by Distal Extension of a Meniscal Cyst: A Case Report.

CASE: We report a 39-year-old man who presented with a painful mass that had been growing over the anteromedial aspect of his left leg for 2 years and was recurrent after an open excisional biopsy. Magnetic resonance imaging showed a lobulated cyst that extended from the medial meniscus. Arthroscopic cyst decompression, anterior cruciate ligament reconstruction, partial meniscectomy, and repair of the meniscotibial capsule were performed. There was no recurrence during the 1-year follow-up. CONCLUSIONS: Arthroscopic cyst decompression and repair of the posterior meniscotibial capsule is a good and safe alternative procedure for the treatment of large-sized meniscal cysts with distal extensions.

Arthroscopic Bony Bankart Repair Using a Double-Row Double-Pulley Technique.

We propose an arthroscopic technique called "double-row double-pulley" to restore a bony Bankart lesion. This technique is a 2-point fixation construct using the sutures from a medial row anchor at the glenoid neck to wrap around the bony Bankart fragment and tie to the sutures from a lateral row anchor at the glenoid rim with the double-pulley method. This technique may present some difficulty with suture management, but there are several advantages. First, due to the 2-point fixation, the risk of a bone piece fracture from direct penetration is minimized. Moreover, the fragment can be reduced directly due to the multiple knots that are tied sequentially over the bony fragment.

Modified Semilateral Decubitus Position for Shoulder Arthroscopy and Its Application for Open Surgery of the Shoulder (One Setting for All Shoulder Procedures).

Two standard patient positions for shoulder arthroscopy are the beach-chair and lateral decubitus positions. Both positions have advantages and disadvantages in many aspects. Surgeons choose the position based on their preferences, mainly the orientation of the anatomy. If an operation needs to be converted to an open procedure, a patient who is placed in the lateral decubitus position might need to undergo repositioning and re-draping, which result in extending the operative time and increasing the risk of infection. For this circumstance, the modified semilateral decubitus position offers the same advantages as the lateral decubitus position and can be adjusted to achieve a more upright position similar to the beach-chair position.

Location of the Neurovascular Bundle of the Knee during Flexed and Extended Position: An MRI Study.

Background: The popliteal vessels and nerve are the structures most at risk during surgery of the posterior knee compartment. Common procedures that could interfere with or otherwise affect these structures include synovectomy, meniscal repair, proximal tibial osteotomy, knee replacement and fixation around the knee joint. Magnetic resonance imaging (MRI) can be used to locate the neurovascular structures from the posterior bony landmark. MRI imaging is routinely studied in the extended knee, but surgery of the posterior knee compartment is most often performed with the knee in a flexed position. Objective: The aim of this study was to investigate the location of the posterior neurovascular bundle relative to the posterior aspect of the femur, tibia, and posterior cruciate ligament during fully extended knee position and 90-degree flexed knee position using MRI. Material and Method: MRI images of 26 knees were obtained from 25 patients. Ten left knees, 14 right knees, and 1 bilateral knees were obtained from 18 males and 7 females. Axial plane and sagittal plane studies were used to measure the shortest distance of the popliteal artery, popliteal vein, and tibial nerve to the posterior bony aspect of the knee and the posterior cruciate ligament using a digital ruler tool from the PACS X-ray system. Measurement was performed at joint line level, 1 cm above joint line level, and 1 cm below joint line level in the fully extended knee position and in the 90-degree flexed knee position. At the joint line level, the mediolateral distance of the popliteal artery, popliteal vein, and tibial nerve to the posterior cruciate ligament were also measured. Results: At 1 cm above joint line level, mean anteroposterior (AP) distance from the distal femoral condyle to the popliteal artery, popliteal vein, and tibial nerve was 1.83+3.35 mm, 6.44+4.55 mm and 10.29+4.41 mm for full knee extension, and 15.60+5.01 mm, 20.63+4.62 mm and 26.24+7.70 mm for 90-degree knee flexion, respectively (p<0.001). At joint line level, mean AP distance from the posterior tibial cortex to the popliteal artery, popliteal vein, and tibial nerve was 5.43+3.22 mm, 8.75+3.72 mm and 13.10+4.15 mm for full knee extension, and 11.64+5.48 mm, 17.59+6.53 mm and 21.52+10.67 mm for 90-degree knee flexion, respectively (p<0.001). At 1 cm below joint line level, mean AP distance from the posterior tibial cortex to the popliteal artery, popliteal vein, and tibial nerve was 1.98+1.95 mm, 4.26+2.74 mm and 8.66+3.85 mm for full knee extension, and 6.91+2.86 mm, 12.34+5.23 mm and 16.58+9.22 mm for 90-degree knee flexion, respectively (p<0.001). At joint line level, mean distance from the posterolateral border of the PCL to the popliteal artery, popliteal vein, and tibial nerve was 11.12+2.62 mm, 11.30+4.05 mm and 15.14+5.05 mm for full knee extension, and 19.89+5.67 mm, 23.87+6.96 mm and 29.41+10.72 mm for 90-degree knee flexion, respectively (p<0.001). Conclusion: During 90-degree knee flexion, the neurovascular structures move posterolaterally, as compared to fully extended knee position at joint line level and 1 cm above and below joint line level. To prevent neurovascular injury during surgery, surgeons should avoid or be cautious during blind penetration of the midline joint capsule and 90 degree flexed knee position increases the distance of the neurovascular bundle away from the posterior bony aspect.

Validity and reliability of Thai version of the International Knee Documentation Committee Subjective Knee Form.

BACKGROUND: Self-administered questionnaires have become an important aspect for clinical outcome assessment of knee-related surgery. The International Knee Documentation Committee (IKDC) Subjective Knee Form is a knee-specific questionnaire that is widely used and translated to many languages. The purposes of the present study were: (1) to translate the questionnaire into Thai; and (2) to assess the validity and reliability of the Thai version of the International Knee Documentation Committee (IKDC) Subjective Knee Form. MATERIAL AND METHOD: The IKDC Subjective Knee Form was translated into Thai using forward-backward translation protocol. Afterward, reliability and validity were tested The responses of 55 consecutive patients on two questionnaires, the Thai IKDC Subjective Knee Form and the Short Form-36, were used. The validity was tested by correlating the scores from both questionnaires. The reliability was adopted by measuring the test-retest reliability and internal consistency. RESULTS: The Thai IKDC Subjective Knee Form showed good correlations with the physical functioning and bodily pain domains of the SF-36 (Pearson's correlation coefficient = 0.75 and 0.76 respectively). The reliability proved excellent with an intra-class correlation coefficient of 0.92 for test-retest. The internal consistency was strong (Cronbach alpha = 0.92). CONCLUSION: The Thai version of IKDC Subjective Knee Form showed good value to retain the characteristic of the original version. In addition, it was a reliable evaluation instrument for patients with knee-related problems.

Pressure ulcers of the thorax after shoulder surgery.

Of 896 patients having arthroscopic or combined arthroscopic and open shoulder procedures at our institution during a 10 year period, three sustained severe pressure ulcerations to the dependent, opposite thorax (one after an arthroscopic procedure, two after combined procedures). These three patients had an average age of 35 years (range 18-50 years) and an average operative time of 107 min (range 82-121 min). During surgery, each patient had an axillary roll (a bag of intravenous fluids) between the dependent thorax and the operative table. Immediate postoperative signs and symptoms included severe pain in the thorax of the nonoperative side and areas of full-thickness skin loss, and blistering. Biopsy of the lesion in one patient was consistent with skin pressure ulceration. At a minimum of 10 months of follow up, all three patients had recovered full range of motion and strength without skin grafting or additional surgery. The exact cause of these lesions is unknown, but we speculate that they resulted from a combination of the use of an intravenous fluid bag as an axillary roll, fluid between the skin and the roll, and friction from moving the patient.

Shoulder arthroplasty versus hip and knee arthroplasties: a comparison of outcomes.

Although outcomes of shoulder, hip, and knee arthroplasties have been well-described, there have been no studies directly comparing the outcomes of these procedures as treatments for osteoarthritis. We compared the inpatient mortality, complications, length of stay, and total charges of patients who had shoulder arthroplasty for osteoarthritis with those of patients who had hip and knee arthroplasties for osteoarthritis. A review of the Maryland Health Services Cost Review Commission discharge database identified 994 shoulder arthroplasties, 15,414 hip arthroplasties, and 34,471 knee arthroplasties performed for osteoarthritis from 1994 to 2001. There were no in-hospital deaths after shoulder arthroplasty, whereas 27 (0.18%) and 54 (0.16%) deaths occurred after hip and knee arthroplasties, respectively. Compared with patients who had hip or knee arthroplasties, patients who had shoulder arthroplasties had, on average, a lower complication rate, a shorter length of stay, and fewer total charges. The latter had 1/2 as many in-hospital complications, were 1/6 as likely to have a length of stay 6 days or greater, and were 1/10 as likely to be charged more than $15,000. We believe shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties.

Laxity testing of the shoulder: a review.

Laxity testing is an important part of the examination of any joint. In the shoulder, it presents unique challenges because of the complexity of the interactions of the glenohumeral and scapulothoracic joints. Many practitioners believe that laxity testing of the shoulder is difficult, and they are unclear about its role in evaluation of patients. The objectives of the various laxity and instability tests differ, but the clinical signs of such tests can provide helpful information about joint stability. This article summarizes the principles of shoulder laxity testing, reviews techniques for measuring shoulder laxity, and evaluates the clinical usefulness of the shoulder laxity tests. Shoulder laxity evaluation can be a valuable element of the shoulder examination in patients with shoulder pain and instability.

Clinical evaluation of impingement: what to do and what works.

Theories about the etiologies of anterior and lateral shoulder pain have changed greatly since "impingement disease" was first described. It is thought that such pain may be caused by contact between the rotator cuff and the acromion and coracoacromial ligament, but the exact pathophysiology of rotator cuff disease remains unclear. The shoulder is notoriously difficult to examine because of the variability of the physical findings in patients with rotator cuff disease. New concepts of impingement, such as coracoid impingement and internal impingement, have been advanced. Although no test is definitive for all causes of anterior and lateral shoulder pain, as the pathophysiology of these conditions becomes better understood the ability to evaluate them clinically also improves.

The reverse shoulder prosthesis: A review of imaging features and complications.

BACKGROUND: The reverse shoulder prosthesis is a prosthesis that has been in clinical use in Europe since 1985 and was approved for use in the United States in 2004. This unique prosthesis has a baseplate attached to the glenoid, which holds a spherical component, while the humeral component includes a polyethylene insert that is flat. This design is the "reverse" configuration of that seen with a conventional arthroplasty, in which the spherical component is part of the humeral component. The indications for the reverse prosthesis are: (1) painful arthritis associated with irreparable rotator cuff tears (cuff tear arthropathy), (2) failed hemiarthroplasty with irreparable rotator cuff tears, (3) pseudoparalysis due to massive, irreparable rotator cuff tears, (4) some reconstructions after tumor resection, and (5) some fractures of the shoulder not repairable or reconstructable with other techniques. This prosthesis can produce a significant reduction in pain and some improvement in function for most of the indications mentioned. However, the unique configuration and the challenge of its insertion can result in a high incidence of a wide variety of unusual complications. Some of these complications, such as dislocation of the components, are similar to conventional shoulder replacement. Other complications, such as notching of the scapula and acromial stress fractures, are unique to this prosthesis. CONCLUSION: The configuration of the reverse prosthesis, its normal radiographic appearance and potential complications associated with its use are reviewed.

Suture anchors and tacks for shoulder surgery, part II: the prevention and treatment of complications.

The use of suture anchors and tacks around the shoulder requires a thorough knowledge of the proper use of the devices and how to insert them. Although typically not technically demanding, suture anchors and tacks can present unique and frustrating challenges to the patient and the surgeon. These challenges can occur whether the procedure is performed via an open or arthroscopic approach, but knowledge of the potential challenges may optimize the surgical result and prevent complications. Complications can be categorized as technique-related or device-related issues (mechanical or biologic failure). Technique-related complications include problems with the delivery systems, anchor malpositioning, and suture management issues, such as knots not sliding. Device-related complications include implant fracture, migration secondary to poor fixation, synovitis from implant degradation, and osteolysis. This review describes the prevention of these and other complications, addresses the indications or need for intervention, and suggests potential solutions when intervention is indicated.

Suture anchors and tacks for shoulder surgery, part 1: biology and biomechanics.

The development and successful clinical application of suture anchors and tacks have revolutionized the surgeon's ability to secure soft tissues to bone via open or arthroscopic surgical techniques. When used carefully and with proper technique, these devices provide viable options for the repair and reconstruction of many intra-articular and extra-articular abnormalities in the shoulder, including rotator cuff tears, shoulder instability, and biceps lesions that require labrum repair or biceps tendon tenodesis. Like many technologies, however, the successful application of these devices requires an understanding of the biology and biomechanics that affect their use in the shoulder as well as knowledge of the factors that can affect subsequent clinical outcomes, including complications.