Does the upward migration index predict function and quality of life in arthroscopic rotator cuff repair?

BACKGROUND: Although upward humeral head migration is a well-recognized phenomenon in patients with tears of the cuff, it is unclear whether it relates to patient function after cuff repair. The upward migration index (UMI) assesses proximal migration of the humeral head while controlling for patients' bony morphologic features. QUESTIONS/PURPOSES: We asked whether functional and quality-of-life (QOL) improvement occurs longitudinally in patients with low, moderate, or high degrees of proximal humeral migration after arthroscopic cuff repair and whether differences occur between groups. PATIENTS AND METHODS: We retrospectively reviewed 118 patients with full-thickness tears treated by arthroscopic cuff repair. Patients were divided into three groups depending on the severity of preoperative proximal humeral migration seen on MRI. We determined function using two functional scores and the Western Ontario Rotator Cuff Index (a QOL index). Evaluations were performed preoperatively and 6 and 12 months postoperatively. A general linear model analysis controlled for patient characteristics, including the UMI, to determine their effects on functional and QOL scores. RESULTS: Function and QOL improved after surgery in all three groups. The UMI did not correlate with final functional or QOL scores. Six-month functional and QOL scores correlated with final scores. The best predictor of final strength was initial strength. CONCLUSIONS: Preoperative UMI did not correlate with functional or QOL improvements after surgery. The data suggest substantial proximal migration of the humeral head, as measured by the UMI, should not be considered a contraindication to arthroscopic rotator cuff repair.

Scapula fractures.

Fractures of the scapula are rare and the diagnosis and treatment may be unfamiliar to some surgeons. This article outlines a diagnostic work-up and treatment approach for the various types of scapular fractures. The approach helps guide decision making on operative versus nonoperative treatment based on what is known regarding prognosis and outcomes of management. Operative technique and fixation strategies are discussed for the common fracture patterns along with guidelines for postsurgical shoulder rehabilitation.

Infraspinatus delamination does not affect supraspinatus tear repair.

Supraspinatus full-thickness tears with associated infraspinatus delamination are a frequent lesion, although the results of repair have not been reported. We retrospectively identified 35 patients treated for this cuff lesion among 378 open repaired full-thickness cuff tears. The aim of the study was to assess the subjective, objective, and anatomic outcomes of a subset of patients with supraspinatus tears involving delamination of the whole infraspinatus tendon. Thirty of the 35 patients were reviewed with magnetic resonance imaging at a minimum followup of 2 years (mean, 3.5 years; range, 2-6.5 years). The mean nonweighted Constant-Murley score at followup was 80/100 points, with an average gain of 17 points. Magnetic resonance imaging revealed all supraspinatus tendons but two were continuous. We observed no tear of the infraspinatus tendon, although a persistent delamination was present in 11 cases. One half of the patients had minor weakness in external rotation. One third of the infraspinatus muscles had minor fatty infiltration. Conservation of the infraspinatus tendon after closing the delamination did not seem to compromise the outcome of the supraspinatus repair. Avoiding resection of the infraspinatus delamination and treatment with simple curettage and closure yields satisfactory midterm functional and anatomic results.

Prospective evaluation of two diagnostic apprehension signs for posterolateral instability of the elbow.

Posterolateral rotatory instability (PLRI) of the elbow occurs from attrition of the lateral ulnohumeral collateral ligament of the elbow after elbow dislocation. Diagnosis by physical examination can be difficult in the awake patient. The goals of this study were to define two active apprehension signs for the physical diagnosis of PLRI and to perform a prospective evaluation of the signs in a series of patients with PLRI. Eight patients with PLRI undergoing surgical reconstruction of the lateral ulnocollateral ligament of the elbow were prospectively included in this continuous case series. Preoperative evaluation consisted of physical examination with two active apprehension signs, the chair sign and the pushup sign, as well as the pivot-shift sign. Results were compared with repeat physical examination after reconstruction of the ligaments. Of 8 patients included in the series, 3 demonstrated a positive pivot-shift sign while awake, and all demonstrated a positive pivot-shift sign while under anesthesia. Seven patients demonstrated a positive chair sign, and seven demonstrated a positive pushup sign. At the 2-year follow-up evaluation, 7 patients remained stable and asymptomatic. The pushup sign, chair sign, and pivot-shift sign were negative in all 7 patients. The study demonstrated that both the pushup and chair signs are effective in aiding the diagnosis of PLRI. They are more sensitive than the pivot-shift sign in the awake patient and may be easily performed in the office environment.

Arthroscopic debridement of the elbow for arthrofibrosis resulting from nondisplaced fracture of the radial head.

PURPOSE: Mason type I fractures of the radial head consist of fractures that occur without displacement. Arthrofibrosis is a rarely reported complication of Mason I radial head fractures. Symptoms include pain, stiffness, and crepitus. We assessed the efficacy of an arthroscopic procedure including debridement and capsular release for patients with persistent symptoms and failure of nonoperative therapy. TYPE OF STUDY: Therapeutic study, case series. METHODS: Retrospective analysis of functional outcome data was carried out for all eligible cases treated at our institution between 1995 and 2003. Twenty procedures were performed, with 8 patients lost to follow-up. The outcome data consisted of range of motion measurements and functional indices derived from the Mayo Performance Index (MPI). Mean follow-up duration was 54 months. RESULTS: Surgical findings included extensive scarring in the radiocapitellar joint, cartilage loss in the radial head and capitellum, scarring and synovitis in the ulnohumeral joint, and scarring with adhesions in the posterior compartment and posterolateral gutter. The mean MPI score preoperatively was 64.1 and the mean postoperative score was 89.5. Total range of motion arc rose from 108 degrees preoperatively to 126 degrees postoperatively. CONCLUSIONS: The outcome data suggest that arthroscopic debridement and capsular release is an effective method of treating arthrofibrosis resulting from Mason I radial head fractures. LEVEL OF EVIDENCE: Level IV.

The effect of the wafer procedure on pressure in the distal radioulnar joint.

PURPOSE: To investigate the effect of the wafer procedure on pressure within the distal radioulnar joint. METHODS: The effect of increasing transverse distal ulnar head resection with preservation of the ulnar styloid was evaluated in 4 fresh frozen cadaver arms. Specimens were tested in neutral rotation. A standard transaxial load was applied from the radius to the ulna and the distal radioulnar joint intra-articular pressure was evaluated. RESULTS: Increasing amounts of distal ulnar resection led to a linear increase in pressure in the distal radioulnar articulation. CONCLUSION: The wafer procedure leads to an increase in pressure in the distal radioulnar joint that may lead to the early onset of osteoarthritis.

Analysis of a school bus collision: mechanism of injury in the unrestrained child.

INTRODUCTION: The most common type of school bus crash resulting in injury and death involves the "rollover" mechanism, which may be linked to bus design. To investigate this possibility, we carried out a detailed investigation of a severe school bus crash. METHODS: The crash involved 12 children, passengers in the school bus. Analysis included the determination of crash dynamics by examination of physical evidence at the crash site and deformation sustained by the structure of the bus and the other vehicle involved. The mechanism of injury was determined by comparing physical evidence collected inside the bus to injuries sustained by the children. RESULTS: Two children sustained severe injuries and 1 child was killed. The most common injuries involved the head, neck and shoulder as demonstrated by 3 illustrative reports. Specified changes to school bus design, based on mechanism of injury to the occupants include, in addition to the compartmentalization now in effect, more padding to the sides of the bus, over the window headers and on the panelling between the windows. CONCLUSIONS: Injuries to the head, neck and spine are the most common types when children are involved in rollover school bus collisions. For additional safety, changes to the current bus design are needed.