Hill-Sachs Remplissage Procedure Based on Posterosuperior Capsulomuscular Anatomy.

The remplissage technique is a procedure designed to fill a posterosuperior humeral head defect with the infraspinatus tendon and posterior-superior capsule in patients with engaging Hill-Sachs lesions. We describe a remplissage technique using 2 posterior working portals that respects the anatomy of the posterior-superior area of the glenohumeral joint without compromising the vascularization.

Do Articular-Sided Partial-Thickness Rotator Cuff Tears After a First-Time Traumatic Anterior Shoulder Dislocation in Young Athletes Influence the Outcome of Surgical Stabilization?

BACKGROUND: Because of the high risk for redislocations after a first-time traumatic anterior shoulder dislocation with conservative treatment, recent publications have recommended early arthroscopic intervention, especially for young athletes. Concomitant rotator cuff tendon damage may occur when the shoulder dislocates; however, its presence and influence on clinical results have not been well described in this patient category. HYPOTHESIS: In opposition to current opinion, a substantial number of articular-sided partial-thickness rotator cuff tears (APTRCTs) would be found at surgery after a first-time traumatic anterior shoulder dislocation in young athletes. However, the impact of these injuries on 2-year postoperative results would be negligible. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Sixteen male patients (mean age, 21 years [range, 16-25 years]) with a first-time traumatic anterior shoulder dislocation without bony Bankart lesions were included in this study. The indications for surgical treatment were age less than 25 years and being active in collision or contact sports at a competitive level. Arthroscopic surgery was performed at a mean 7.8 days (range, 2-14 days) after injury. Rowe and American Shoulder and Elbow Surgeons (ASES) scores as well as range of motion were evaluated at a minimum 2 years after an arthroscopic Bankart procedure, and a comparison of the clinical results between patients with and without APTRCTs was conducted. RESULTS: An anterior-inferior capsulolabral injury was found in all patients. There were no bony Bankart lesions. An APTRCT was found in 9 of the 16 patients. At 2 years after surgical treatment, there were no significant differences between the patients with and without APTRCTs in terms of the Rowe score (90.0 and 87.1, respectively; P = .69) and ASES score (94.6 and 90.4, respectively; P = .67). CONCLUSION: APTRCTs were found in the superior part of the shoulder joint after a first-time traumatic anterior shoulder dislocation in a majority of young male athletes treated with surgical stabilization. There were no significant differences found between patients with and without APTRCTs in terms of the Rowe and ASES scores at 2 years after surgical treatment.

The glenocapsular ligament and the posterosuperior part of the joint capsule of the shoulder are well vascularized.

PURPOSE: A detailed structural anatomy of the posterosuperior shoulder capsule and "glenocapsular ligament" is still rather unknown. The purpose of this study was meticulously to investigate and describe the structure and blood supply of the glenocapsular ligament on the posterosuperior shoulder joint capsule. METHOD: Sixteen fixed and twelve fresh cadaveric shoulder specimens with a mean age of 73.4 (±6.4) years were analysed. Dissection without arterial injection was performed on the 16 fixed specimens-using an alcohol-formalin-glycerol solution. Before dissection, the 12 fresh specimens received of arterial injection a 10% aqueous dispersion of latex solution. After the injection, these shoulders were also fixed in an alcohol-formalin-glycerol solution. RESULTS: The glenocapsular ligament was found in all 28 specimens. Single or double parallel-running bundles of connective tissue fibres were found to form a capsular-ligamentous structure on the posterosuperior part of the joint capsule. One part of the ligament was mediosuperior, another posterosuperior. The mediosuperior part varied in shape, and in 12 of 28 cases, it was absent. The glenocapsular ligament arose from the supraglenoid tubercle and posterior part of the collum scapulae and inserted into the semicircular humeral ligament. The posterior ascending branch of the circumflex scapular artery directly fed small branches laterally and medially to the joint capsule, supplying the glenocapsular ligament and the deep layer of the joint capsule. CONCLUSION: The glenocapsular ligament is a constant anatomical structure that consists of one or two different parts. The glenocapsular ligament and the posterosuperior part of the joint capsule appear well vascularized via the posterior ascending branch of the circumflex scapular artery. CLINICAL RELEVANCE: It is the hope of the authors that this anatomical study can help surgeons who perform open or arthroscopic surgery to the posterior part of the shoulder. Knowledge of the vascular anatomy presented in this study may be especially important when incisions are made to the posterior part of the shoulder, and should minimize the risk of complications.

Blood supply of the subacromial bursa and rotator cuff tendons on the bursal side.

PURPOSE: Vascularity of the subacromial bursa and rotator cuff tendons is key factors in the pathogenesis of subacromial bursitis and impingement syndrome, rotator cuff tendinitis, and rotator cuff tears. The purpose of this study was to investigate and describe blood supply to the cranial and caudal parts of the subacromial bursa and the vascularity of the rotator cuff tendons on the bursal side. METHODS: Fourteen fresh cadaveric shoulders from six females and eight males with a mean age of 71.7 (±10.8) years were studied. Before dissection, an arterial injection of 10% aqueous dispersion of latex was administered. Post-injection, the shoulders were fixed in an alcohol-formalin-glycerol solution. RESULTS: The cranial and caudal bursa of all specimens was mainly supplied by the thoracoacromial, suprascapular, and anterior and posterior circumflex humeral arteries. The cranial part of the bursa was supplied anteriorly by the thoracoacromial artery, and posteriorly and medially by the posterior circumflex humeral artery as far as the medial third. The caudal part received arterial blood anteriorly from the anterior circumflex humeral artery, and posteriorly and medially by the posterior circumflex humeral artery as far as the medial third of the caudal bursa. In addition, the suprascapular artery branched at the upper surface of the coracohumeral ligament, and the subcoracoid artery branched at the under surface of the same ligament. CONCLUSION: The subacromial bursa appears well vascularized. The results of the present investigation showed that blood supply to the subacromial bursa at the caudal part and rotator cuff tendons on the bursal side was linked to the same arteries. The subcoracoid artery supplied interval rotator structures close to the caudal bursa. It is the wish of the authors that this meticulous anatomical work will help surgeons in their day-to-day clinical work, e.g. to minimize the risk of complications such as perioperative bleeding.

Rotator cuff tendon connections with the rotator cable.

PURPOSE: The literature currently contains no descriptions of the rotator cuff tendons, which also describes in relation to the presence and characteristics of the rotator cable (anatomically known as the ligamentum semicirculare humeri). The aim of the current study was to elucidate the detailed anatomy of the rotator cuff tendons in association with the rotator cable. METHODS: Anatomic dissection was performed on 21 fresh-frozen shoulder specimens with an average age of 68 years. The rotator cuff tendons were dissected from each other and from the glenohumeral joint capsule, and the superior glenohumeral, coracohumeral, coracoglenoidal and semicircular (rotator cable) ligaments were dissected. Dissection was performed layer by layer and from the bursal side to the joint. All ligaments and tendons were dissected in fine detail. RESULTS: The rotator cable was found in all specimens. It was tightly connected to the supraspinatus (SSP) tendon, which was partly covered by the infraspinatus (ISP) tendon. The posterior insertion area of the rotator cable was located in the region between the middle and inferior facets of the greater tubercle of the humerus insertion areas for the teres minor (TM), and ISP tendons were also present and fibres from the SSP extended through the rotator cable to those areas. CONCLUSION: The connection between the rotator cable and rotator cuff tendons is tight and confirms the suspension bridge theory for rotator cuff tears in most areas between the SSP tendons and rotator cable. In its posterior insertion area, the rotator cable is a connecting structure between the TM, ISP and SSP tendons. These findings might explain why some patients with relatively large rotator cuff tears can maintain seamless shoulder function.

Anatomy of the superior glenohumeral ligament.

BACKGROUND: The aim of the present study was to give a detailed, anatomical description of the superior glenohumeral ligament and its relationship with the neighbouring structures in the rotator interval. METHOD: Twenty-seven cadaveric shoulder specimens were dissected in fine detail to describe superior glenohumeral ligament and additional histologic examination was performed. RESULTS: The superior glenohumeral ligament is a constant, gross anatomic structure that was present in all of twenty-seven investigated specimens. The fibers of the superior glenohumeral ligament could be divided into two groups - the oblique and direct fibers. The direct fibers of the superior glenohumeral ligament arise from the glenoid labrum, run parallel with the tendon of the long head of the biceps brachii towards the lesser tubercle, which they also partly insert onto. The rest of the direct fibers course into the bottom of the bicipital groove and bridge over it, forming the superior part of the transverse humeral ligament. The oblique fibers arise from the supraglenoid tubercle, run over the intraarticular part of the tendon of the long head of the biceps brachii and insert below the coracohumeral ligament into the humeral semicircular ligament. CONCLUSION: Due to its anatomic composition and tight connection with the neighboring articular structures, the superior glenohumeral ligament is involved in the stabilizing mechanisms of the intraarticular part of the tendon of the long head of the biceps brachii and plays an important role in the variety of clinical disorders that occur within the rotator interval.

The spiral glenohumeral ligament: an open and arthroscopic anatomy study.

PURPOSE: The purpose of this study was to visualize arthroscopically and to describe the micro- and macroscopic anatomy of the poorly known ligament of the anterior capsule of the glenohumeral joint: the so-called ligamentum glenohumerale spirale (spiral GHL). METHODS: Twenty-two fresh shoulder joints were dissected, and the anatomy of the anterior capsular structures (the spiral GHL, the middle glenohumeral ligament [MGHL], and the anterior band as well as the axillary part of the inferior glenohumeral ligament [AIGHL and AxIGHL, respectively]) was investigated. For arthroscopic visualization, 30 prospective arthroscopic clinical cases and 19 retrospective video clips of the patients who had an arthroscopic shoulder procedure with a normal subscapularis tendon, labrum, and anterior joint capsule were evaluated. RESULTS: The spiral GHL and the AxIGHL were present in all 22 shoulder specimens. The AIGHL was not recognizable on the extra-articular side of the joint capsule. The MGHL was absent in 3 shoulder specimens (13.6%). Arthroscopically, the spiral GHL was found in 22 (44.9%), the MGHL in 43 (87.8%), and the AIGHL in 46 (93.9%) of the cases. The spiral GHL arose from the infraglenoid tubercle and the triceps tendon and inserted together with subscapularis tendon onto the lesser tubercle of the humerus. CONCLUSIONS: Our results suggest that extra-articular structure of the spiral GHL is consistently recognizable, the upper part of which can be arthroscopically identified. CLINICAL RELEVANCE: Advanced anatomic knowledge of the spiral GHL helps the clinician better understand the normal anatomy of the shoulder joint and also helps to differentiate it from pathologic findings of the patient. The biomechanical importance of the spiral GHL and its connection with shoulder pathology remains to be determined in further studies.

Magnetic resonance imaging and correlative gross anatomy of the ligamentum semicirculare humeri (rotator cable).

The purpose of this study has been to demonstrate macroscopic and MRI anatomy of the so-called rotator cable, otherwise known as the ligamentum semicirculare humeri (LSCH) of the superior shoulder joint capsule. Twelve shoulder joints from eight cadavers were dissected; seven of which, from four of the cadavers, were studied using MR arthrography (1.5-Tesla device Somatom Symphony, Siemens, Erlangen, Germany) prior to dissection. The MRI protocol included T1WI, PDWI, and DESS 3D WI standard sequences. The results of MRI were compared with gross anatomic dissection findings. The macroscopically recognizable capsular bundle of LSCH fibers was identified by anatomic dissection in all specimens. On MRI, the entire ligament or parts of it could be identified in six of seven cases. It was best visualized on axial images. In the evaluation of magnetic resonance images of superior shoulder joint structures, additional knowledge on the anatomy of the LSCH can be used by the radiologist to facilitate detailed interpretation of the shoulder MRI.

Cerebral oxidative metabolism in rats with high and low exploratory activity.

To reveal brain regions most significantly related to individual differences in exploratory behaviour, oxidative metabolism was measured by cytochrome c oxidase histochemistry in 2 months old Wistar rats with persistently high (HE) or low (LE) exploratory activity in a novel environment. LE-rats had significantly higher levels of oxidative metabolism in dorsal raphe and inferior colliculi. In contrast, HE-rats had higher metabolic activity in entorhinal cortex. In conclusion, rats with different exploratory styles differ in underlying cerebral activity as measured via oxidative metabolism in regions implicated in defensive behaviours and cognitive processing of sensory stimuli.

Division of the male rat rhabdosphincter into structurally and functionally differentiated parts.

In order to understand the structure-function relationship in the male rat rhabdosphincter, the 3D structure of the striated muscle and associated dense connective tissue was reconstructed from representative serial sections cut from the proximal urethra harboring the muscle. The 3D structure was correlated with electromyography (EMG) of the rhabdosphincter, urodynamic parameters (bladder pressure and flow rate), and longitudinal contraction force of the proximal urethra. The muscular component of the rhabdosphincter consisted of a homogeneous population of the fast-twitch-type fibers. In the cranial part, striated muscle formed a complete ring encircling the urethra, deferent ducts, and ducts from seminal vesicles and prostatic lobes. Toward the middle part, the amount of densely packed connective tissue lacking type III collagen increased anteriorly and posteriorly and penetrated the muscular ring that became divided first posteriorly and then anteriorly into two symmetrical halves. In the caudal part, a thin midsagittal dense connective tissue septum remained posteriorly. EMG recordings suggested that the rhabdosphincter muscle was functionally divided into two parts. Unlike the cranial and middle parts, the caudal part did not show the first depolarization peak. It appears that rapid oscillatory oblique-to-circular muscular contractions proceeding in craniocaudal direction in the cranial and middle part draw the anterior wall supported by arch-like dense connective tissue closer to the posterior wall supported by a more rigid rhomboidal raphe. Longitudinal contractions of the urethra are possibly evoked from the proximal and caudal parts of rhabdosphincter. These could lead to simultaneous increase in urethral pressure ensuring rapid urine flow rate. The caudal part could augment the opening of urethral lumen during oscillatory voiding.

Shoulder function in patients with frozen shoulder before and after 4-week rehabilitation.

UNLABELLED: This study evaluated changes in shoulder function in patients with frozen shoulder after 4-week rehabilitation combining exercise with electrical therapy and massage. MATERIAL AND METHODS: Ten patients with frozen shoulder (mean +/- standard error (SE) age 50.2+/-4.6 years) and 10 control subjects (49.8+/-4.6 years) participated in the study. Standard goniometric measurements were used to assess shoulder flexion, extension, abduction, adduction, internal and external rotation active range of motion. Isometric maximal force of the shoulder flexors, abductors, adductors, internal and external rotators was measured by hand-held dynamometer. Shoulder muscle isometric endurance was characterized by net impulse assessed during weight (30% of maximal force) holding in hand till exhaustion. Shoulder pain was assessed by visual analogue scale. RESULTS: Before rehabilitation, patients with frozen shoulder had less (p<0.05) active range of motion and shoulder muscle maximal force for all measured directions, and less (p<0.05) net impulse during shoulder muscle isometric endurance test for involved extremity compared to controls. In patients with frozen shoulder, shoulder flexion, abduction, adduction and adduction active range of motion, maximal force of shoulder muscles in all measured force directions and net impulse during shoulder muscle isometric endurance test for involved extremity increased (p<0.05) after rehabilitation. No significant changes in shoulder internal and external rotation active range of motion for involved extremity in patients with frozen shoulder were observed with rehabilitation. CONCLUSION: A 4-week rehabilitation program improved shoulder flexion, extension, abduction and adduction active range of motion in patients with frozen shoulder coupled with non-significant changes in external and internal rotation range of motion. A significant increase in shoulder muscle isometric strength and endurance and decrease in shoulder pain in patients with frozen shoulder was observed after treatment.

Low-dose radiation modifies the progression of chronic renal failure.

Previous studies have indicated that the application of low dose radiation to an arterial ligation has the potential to subsequently reduce or eliminate restenosis caused by smooth muscle cell proliferation. Sufficient kidney irradiation causes a radiation nephropathy and often leads to renal failure. In order to evaluate the effect of low-dose irradiation on the kidney we hypothesized that this particular therapy modifies renal injury in rats with renal ablation and subsequently slows the rate of the progression. For further clarification of the effect of irradiation at low doses, we determined proliferating cell nuclear antigen (PCNA) and monocyte chemoattractant protein-1 (MCP-1) expression in remnant kidneys after low-dose radiation. Adult Wistar rats (n = 10) were studied during the two weeks after renal ablation. The left kidney was irradiated 24 hours after an operation in anaesthetised animals with 3 Grey in a single dose. Ablated rats without irradiation (n = 9) served as nephrectomized animals group. Rats without surgery and without radiation (n = 10) served as healthy controls. Renal damage was assessed using the following parameters: urine protein excretion rate (UprotV, mg/day), awake systolic blood pressure (SBP, mm Hg), serum creatinine (SCr, micromol/l). The indirect immunofluorescence method was used for the detection of PCNA and MCP-1 expression. Glomerular and tubular immunostaining was scored semiquantitatively. Numerous PCNA positive cells and MCP-1 expression were present in the glomerulus and tubulointerstitium in nephrectomized rat kidneys. Low-dose radiation application was associated with a significant reduction in PCNA and low MCP-1 expression. This study shows that the application of low-dose irradiation has the potential to modify the progression of chronic renal failure in rats.

Decrease in laminin content and protein excretion rate after five sixths nephrectomy and low-dose irradiation in the rat.

The effect of low-dose irradiation on laminin distribution and urine protein excretion in the remnant rat kidney has been studied. The rat remnant kidney formed after 5/6 nephrectomy is an experimental model of chronic renal failure. In the remnant kidney, focal segmental glomerulosclerosis is developed characterized by focal or segmental sclerosis in glomeruli, alterations in the tubules and thickening of the glomerular basement membrane. Low dose irradiation has been presumed to suppress sclerotic processes. In this study 24 male Wistar rats were subdivided into the nephrectomized group, nephrectomized and irradiated groups (1 or 3 Grey), and healthy control group. Animals were sacrificed at 2, 4 and 8 weeks after beginning the experiment. Laminin immunohistochemical staining was found along the tubular and glomerular basement membranes in all experimental groups, but with varying intensity. Laminin content in the basement membranes was decreased in early stages (week 2), especially after irradiation followed by increase during the later stages with relatively high levels at the end of the experiment (week 8). Irradiation at a dose of 3 Grey decreased protein excretion compared to the nephrectomized rats at all stages, while 1 Grey dose was ineffective. Based on decreased proteinuria we conclude that moderate low-dose irradiation has beneficial effects on the rat remnant kidney and that laminin in basement membranes is probably not the most crucial component in regulating membrane permeability.

Denervation of the locus coeruleus projections by treatment with the selective neurotoxin DSP-4 [N (2-chloroethyl)-N-ethyl-2-bromobenzylamine] reduces dopamine release potential in the nucleus accumbens shell in conscious rats.

Pretreatment with DSP-4, a neurotoxin highly selective for the locus coeruleus (LC) noradrenergic projections, 2 weeks before in vivo microdialysis in conscious rats had no effect on baseline extracellular dopamine (DA) levels in the nucleus accumbens shell, but reduced dose-dependently the dopamine response to depolarisation induced by 50 mM KCl. DA metabolism in the frontal cortex, as measured ex vivo, was increased in animals treated with a low (10 mg/kg) but not with a high dose (50 mg/kg) of DSP-4, possibly indicating an increased sensitivity to stress in these animals and thus suggesting differential regulation of DA in the forebrain by the LC lesions. The reduced DA release potential in the nucleus accumbens after DSP-4 treatment suggests that weakening of the LC input to DA nerve cells contributes to motivational deficits.

Carmine-picroindigocarmine: an alternative multiple staining method.

Carmine-picroindigocarmine, a multiple staining method, was developed at the beginning of the previous century by Professor Harry Kull at the University of Tartu. The stain, combining copper carmine, picric acid and indigocarmine gives bright and colourful results. Nuclear structures are stained in red, cytoplasm in varying shades from yellow to green, collagen fibres in blue, the matrix of hyaline cartilage in greyish-blue, muscle tissues from brownish-red to brownish-green, erythrocytes in yellow. Squamous epithelia are stained in red with horney layers in dark red, nail plate and hairs are stained in bright yellow. The carmine-picroindigocarmine staining is stable, which allows for the combining of additional dyes without interfering with the main colouring. The combination of carmine-picroindigocarmine staining with resorcin-fuchsine in principle maintained the colouring of Kull's original method with additional staining of elastic fibres in violet colour that clearly differentiated them from blue stained collagen fibres. The described multiple staining gives an original colourful and aesthetic result, providing an alternative to other multiple staining methods.

Macroscopical anatomy of the so-called "rotator interval". A cadaver study on 19 shoulder joints.

The triangular capsular space between the insertion tendons of the Mm. supraspinatus and subscapularis--the "rotator interval", can be divided into lateral, medio-superior and medio-inferior parts. The lateral part of the capsule is strengthened by the "Lig. semicirculare humeri" and the anterior fibres of the M. supraspinatus tendon. The Ligg. coracohumerale and "coracoglenoidale" are the macroscopical elements of the medio-superior part. The medio-inferior part of the "rotator interval" is reinforced by the Ligg. glenohumeralia superius et medium. The key ligament of the "rotator interval" is the "Lig. semicirculare humeri". Laterally it ensures the insertion of the anterior fibres of the M. supraspinatus tendon above the Lig. transversum humeri and on the Tubercula majus et minus. Medially it is the place of attachment of the Lig. coracohumerale and oblique fibres of the Lig. glenohumerale superius. The "rotator interval" is not a weak capsular region but a complex network of macroscopically recognizable tendinous and ligamentous structures.