The parachute technique: valgus impaction osteotomy for two-part fractures of the surgical neck of the humerus.

Fourteen elderly patients with a two-part fracture, in osteopenic bone, of the surgical neck of the humerus were treated with a valgus impaction osteotomy and tension band fixation--that is, the parachute technique. Thirteen patients were followed, and all were able to perform activities of daily living without difficulty and were satisfied with the result of the surgery. The average age of these thirteen patients was sixty-eight years, and the average duration of follow-up was 18.5 months. Union was achieved in all patients, at an average of 45.5 days. No patient demonstrated osteonecrosis of the humeral head. This technique of valgus impaction osteotomy with Dacron-tape tension band fixation leads to rapid union. Patient satisfaction and function were excellent.

Indications, technique, and results of total shoulder arthroplasty in osteoarthritis.

Osteoarthritis is a slowly progressive disease of one or more joints that appears to primarily affect articular cartilage. A joint affected by osteoarthritis develops cartilage thinning and, ultimately, patches of complete cartilage loss. The main symptom of osteoarthritis in the glenohumeral joint is diffuse, achy, and insidiously progressive pain. Total shoulder arthroplasty has become the standard treatment for advanced osteoarthritis of the glenohumeral joint.

Anterior acromioplasty: effect of litigation and workers' compensation.

Seventy-five consecutive anterior acromioplasties were performed in 74 patients with chronic inflammation of the supraspinatus tendon caused by the impingement syndrome. Thirty-six patients (49%) had filed workers' compensation claims (group 1), 21 patients (28%) were involved in accident litigation (group 2), and 17 patients (23%) had no financial gain associated with their shoulder pain (group 3). The patients were followed up for a minimum of 12 months after surgery (range 12 to 48 months). Sixty-one patients (82%) had excellent results, 11 patients (15%) had good results, and 2 patients (3%) failed to improve from surgery. Ninety-one percent of employed patients were able to return to full employment. Although group 1 patients required a significantly longer time to return to work (average 14.2 weeks vs. 4.7 weeks in group 2 and 2.5 weeks in group 3), these patients were all involved in heavy labor demanding a more complete return of shoulder endurance. Satisfactory pain relief and return to preinjury work activities can be achieved by acromioplasty in patients who have the potential for secondary gain.

Effusion criteria and clinical importance of glenohumeral joint fluid: MR imaging evaluation.

PURPOSE: To investigate the clinical importance of glenohumeral joint (GHJ) fluid. MATERIALS AND METHODS: The amount of GHJ fluid in 17 volunteers and 208 consecutive patients was graded at magnetic resonance imaging with T2-weighted fat-suppressed coronal oblique images by two blinded observers. Thorough historical data and physical examination results were available for 108 patients. Presence and grade of GHJ fluid were correlated with age, sex, presence of osteophytes activity scale, supraspinatus tenderness, clinical impingement, prior subacromial injections, rotator cuff tears (RCTs), joint tenderness, joint pain, and history of trauma. RESULTS: GHJ fluid was seen in 40% (n = 83) of patients and in only 6% (n = 1) of volunteers. The volume of fluid correlated with osteophytes (P = .04), increasing age (P = .0001), and RCTs (P = .005). No correlation was found with activity rating, focal tenderness, joint pain, diagnosis of impingement, impingement grade, supraspinatus insertional tenderness, subacromial injection, prior trauma, or sex. CONCLUSION: The presence of GHJ fluid appears to be abnormal and in most cases is related to RCTs and osteoarthritis. It seems to be unrelated to activity, tenderness, or impingement.

Rotator cuff disorders: interobserver and intraobserver variation in diagnosis with MR imaging.

PURPOSE: To determine interobserver and intraobserver variation in the interpretation of magnetic resonance (MR) images in rotator cuff disorders. MATERIALS AND METHODS: MR images of the shoulder in 97 patients were retrospectively reviewed twice, with a 3-week interval. Surgical findings indicated a full-thickness tear in 29 patients, grade 1 impingement in 19 (tendinitis), and grade 2 impingement (partial tear) in 26. The control population comprised 23 asymptomatic volunteers or patients. RESULTS: All observers were accurate in the diagnosis of a full-thickness tear (89%-98%), with good intraobserver (kappa = 0.67-0.84) and interobserver agreement (kappa = 0.74-0.92). In diagnoses of tendinitis, partial tear, and normal cuff, there were wide ranges of sensitivity (13%-74%) and specificity (72%-93%), as well as poor interobserver (kappa = 0.12-0.60) and intraobserver agreement (kappa = 0.35-0.78). CONCLUSION: Full-thickness tears of the rotator cuff can be accurately identified at MR imaging with little observer variation. Consistent differentiation of normal rotator cuff, tendinitis, and partial thickness tears is more difficult.

Modular total shoulder replacement. Design rationale, indications, and results.

Modular total shoulder systems offer many advantages over nonmodular designs. Modularity facilitates precise placement of the humeral head with respect to the rotator cuff and tuberosities, allows for soft tissue tensioning and balance with variable neck lengths, and simplifies revision surgery by allowing removal of the humeral head while maintaining a well-fixed humeral stem. This review includes 47 total shoulder arthroplasties performed in 40 patients from 1986 to 1991. The average patient age was 62.3 years, with followup averaging 54 months. Seventeen patients had rheumatoid arthritis, and 22 had osteoarthritis. In the remaining 8 patients, 5 had posttraumatic arthritis, 2 had avascular necrosis, and 1 had cuff tear arthropathy. Glenoid revision was required in 3 patients, and symptomatic loosening occurred in only 1. Pain relief was achieved in 93.5% of patients. Range of motion improved 34.9 degrees in forward flexion, 18.1 degrees in external rotation, and 4 vertebral levels of internal rotation. Lucent lines were evaluated on the anteroposterior (AP) and axillary radiographs. On the AP radiograph, 16 shoulders demonstrated lucency about the glenoid component. Progression beyond 2 mm occurred in 5 shoulders, and symptoms requiring revision developed in one patient. Twenty-two patients demonstrated a lucency on the axillary radiograph, and 9 patients progressed beyond 2 mm. None required revision. The authors present the results and discuss surgical and design considerations of modular total shoulder arthroplasty.

Rotator cuff disease: a review of diagnosis, pathophysiology, and current trends in treatment.

This article reviews the anatomy, pathophysiology, and treatment of rotator cuff disease. A plan is presented to assist the clinician in making the appropriate diagnosis and proceed with adequate workup and treatment of a patient with shoulder pain.

Ganglion cysts about the shoulder girdle in the absence of suprascapular nerve involvement.

Ganglion cysts about the shoulder girdle are being identified with increasing frequency by the magnetic resonance image scanner. These masses rarely become evident clinically unless they cause compression of the suprascapular nerve. In this series a ganglion not causing compression of the suprascapular nerve was identified in each of five patients. Three of these patients had shoulder pain, tenderness over the supraspinotus muscle, and an increase in pain with abduction in the plane of the scapula. Plain radiographs showed erosion of the scapular neck. In the remaining two patients the pain pattern was consistent with an impingement syndrome in one and a rotator cuff tear in the other. Successful operative resection was undertaken on three patients. In two of these patients the magnetic resonance image scan helped determine the need for simultaneous exposure of the suprospinous and infraspinous fossae by means of scapular spine osteotomy. In the two patients not believed to be symptomatic from their ganglia, treatment for the primary shoulder diagnosis resulted in complete relief of symptoms. In the absence of suprascapular nerve involvement, the presence of a ganglion cyst in the shoulder girdle is not an absolute indication for operative resection. In the presence of another common shoulder diagnosis, treatment for that diagnosis should be pursued.

Hooked acromion: prevalence on MR images of painful shoulders.

An association between the morphology of the acromion and the occurrence of rotator cuff tear (RCT) has been suggested by findings at both pathologic examination and routine radiography. As a tomographic technique, magnetic resonance (MR) assessment of acromial shape may be more accurate than routine radiography. The authors studied acromial morphology on sagittal oblique MR images of a control population (47 shoulders), of patients with isolated impingement (30 shoulders), and of patients with full-thickness RCTs (34 shoulders) to assess the association of acromial shape with disorders of the rotator cuff. Acromions were classified as flat (type 1), smoothly curved (type 2), or hooked (type 3). Data were collected by two observers, blinded to clinical and surgical information, who acted in consensus. Patients with RCT had a significantly increased prevalence of type 3 acromions compared with control patients (62% vs 13%, P < .001). Type 3 acromions tended to be more prevalent in the group with impingement (30%, P = .17). There was no significant difference in the distribution of acromion types among control patients with respect to age or gender.

Modular total shoulder: early experience and impressions.

All design considerations in shoulder arthroplasty are based on reconstructing normal anatomy and enhancing prosthetic fixation, particularly on the glenoid side. These goals are further enhanced by meticulous attention to detail in placement of the component parts relative to the bony anatomy. In addition, great attention must be paid to management of the soft tissue tensions and placement of the component parts relative to soft tissue origins and insertions so that asymmetric overloading of the components can be avoided and loosening and wear can be minimized. The problem of management of prosthetic replacement with associated massive rotator cuff tears continues to be a dilemma. Use of an oversized humeral head articulating with the acromion can offer a compromise solution to the problem. This technique can be combined with altered glenoid component placement or reshaping of the bony glenoid to accommodate its altered relationship with the humeral articular surface. Future design changes are needed to deal with this complex problem.

Rotator cuff tears: prospective comparison of MR imaging with arthrography, sonography, and surgery.

Thirty-eight patients with suspected rotator cuff tears were examined at 1.5 T by using a loop-gap resonator surface coil. The MR findings were compared prospectively in a blinded fashion with the results from double-contrast arthrography in all 38 patients, high-resolution sonography in 23 patients, and surgery in 16 patients. In the total group of 38 patients, MR imaging detected 22 of 22 tears and 14 of 16 intact cuffs as determined by arthrography. In the 16 surgically proved cases, MR and arthrography showed identical results, with 92% sensitivity in the diagnosis of 12 tears and 100% specificity in the diagnosis of four intact cuffs. In a subgroup of 23 patients, sonography detected nine of 15 tears and seven of eight intact cuffs as determined by comparison with arthrography. In 10 surgically proved cases, sonography was 63% sensitive in the diagnosis of eight rotator cuff tears and 50% specific in the diagnosis of two intact cuffs. For the diagnosis of rotator cuff tears, MR imaging is comparable to arthrography in both sensitivity and specificity. In this study, sonography was not as accurate in the diagnosis of rotator cuff tears as were the other two techniques. These results suggest that MR imaging should be considered the noninvasive test of choice for patients with suspected rotator cuff disease.

Limited sensitivity of ultrasound for the detection of rotator cuff tears.

Bilateral rotator cuff sonography was performed on 56 patients referred for shoulder arthrography to detect rotator cuff tears. Since one patient had bilateral arthrography there were 57 arthrograms. Twenty-seven shoulders had rotator cuff tears shown on arthrography, 15 of which were detected by sonography. Eleven were false negative by sonography, and one was indeterminate. Of the 30 shoulders with negative arthrograms, 28 had normal sonograms and two were false positive. Sensitivity was 58%, specificity was 93% and overall accuracy was 77%. The positive and negative predictive values were 88% and 72%. These results suggest that sonography has limited value in screening patients for rotator cuff tears and that a positive sonographic reading is more reliable than a negative one. Theories relating to the variable anatomic configuration of a tear are postulated to explain these results, which differ from those previously reported.

Conservative open anterior acromioplasty.

The records of 29 consecutive patients treated by a pure, open, anterior acromioplasty were reviewed retrospectively. Excluded from consideration were patients with the following pathologic diagnoses or histories: (1) previously attempted acromioplasty on the same shoulder; (2) intraoperatively confirmed rotator cuff tear; (3) any surgically treatable biceps tendon or acromioclavicular abnormality; (4) lost to follow-up study. Three different techniques were employed to perform the acromioplasties. The first technique required partial deltoid origin detachment with an osteotome. The second technique spared the deltoid origin, while again using an osteotome to perform the acromioplasty. The third technique also spared the deltoid origin but used a high-speed burr to perform the acromioplasty. Evaluated in terms of patient satisfaction, residual pain, length of convalescence, suboptimal results, and complications, the first technique proved to be the least effective. The second technique produced early, excellent results. The third technique, in which a burr was employed through an intact deltoid origin, was most effective; technically, the method was also relatively simple and reliable.

Results of surgical intervention in the symptomatic multiply-operated back patient. Analysis of sixty-seven cases followed for three to seven years.

Sixty-seven of seventy-three patients who had had multiple operations on the back with an initial diagnosis of lumbar-disc disease were reevaluated as to relief of pain two and four years after the most recent operation. More than 80 per cent of the patients had gained enough relief to deem the procedure worth while. A diagnosis of fibrosis, preoperatively or intraoperatively, portended a poor result, while the opposite was true with diagnoses of mechanical compression (disc fragment or stenosis) and instability (pseudarthrosis after fusion or spondylolisthesis). The presence of a pain-free interval lasting one year from the date of the previous operation correlated highly with the presence of a surgically remediable lesion.

Total glenohumeral joint replacement.

Some of the anatomical considerations of the glenohumeral joint with respect to prosthetic replacement have been discussed. One approach to prosthetic design has been presented along with the early clinical experience with this design. It is hoped that this information will serve as a reference point for future work to be done in this area.