Shoulder Proprioception: A Review.

The purpose of this review is to provide a comprehensive resource for shoulder proprioception assessment and its integration into clinical decision making as well as targeted rehabilitation protocols. Data for this review were acquired from peer-reviewed articles from computerized online databases, namely PubMed and Medline, published between 1906 and 2021. The development of digital/smart phone goniometers can improve shoulder joint range of motion (ROM) measurements and demonstrate comparable measurement accuracy to the universal standard goniometer. The inclinometer offers a portable and cost-effective method for measuring shoulder joint angles and arcs of motion in the vertical plane. Two types of dynamometers, the computerized isokinetic machine and the handheld hydraulic dynamometer, are reliable tools for objective shoulder rotator cuff strength assessment. Motion analysis systems are highly advanced modalities that create three-dimensional models of motion arcs using a series of cameras and reflective beads, offering unparalleled precision in shoulder proprioception measurement; however, they require time-consuming calibration and skilled operators. Advancements in wearable devices and compact mobile technology such as iPhone applications may make three-dimensional motion analysis more affordable and practical for outpatient settings in the future. The complex interplay between proprioception and shoulder dysfunction is not fully understood; however, shoulder proprioception can likely both contribute to and be caused by shoulder pathology. In patients with rotator cuff tears, glenohumeral osteoarthritis, and shoulder instability, clinicians can track proprioception to understand a patient's disease progression or response to treatment. Finally, rehabilitation programs targeting shoulder proprioception have shown promising initial results in restoring function and returning athletes to play.

Bilateral Lower Extremity Calcific Myonecrosis: A Case Report.

Introduction: Calcific myonecrosis is a rare soft-tissue disease where a single muscle or muscle compartment is replaced with central liquefaction and peripheral calcification. This disease usually occurs in a single limb after trauma. Until now, bilateral muscle involvement has not been previously reported. Case Report: A 73-year-old woman presented with symptomatic masses in the soft tissues of bilateral anterior thighs. She had no known history of trauma but recalled a specific tearing sensation episode in both her legs while squatting when weightlifting in the distant past. The patient had calcified masses that had replaced the rectus femoris muscle bilaterally with associated effects on hip and knee range of motion. The patient underwent excision of a portion of calcific myonecrosis and two locations of rectus femoris tenotomies in one leg and only a simple rectus femoris tenotomy on the contralateral leg. The patient subsequently experienced a significant improvement in hip and knee motion and a reduction in associated pain on both sides. Conclusion: Historical and radiographic information are key in making the diagnosis of calcific myonecrosis. Treatment decisions should be based on the patient's symptoms balanced with the morbidity of the expected procedures. Symptomatic patients should be considered for excision of the symptomatic involved areas. A tenotomy may be a viable option if a limitation in motion is the primary complaint. Asymptomatic patients with a stable lesion and imaging should undergo conservative management due to the high risk of infection and wound healing problems.

Spontaneous Diffuse Pyoderma Gangrenosum after Polytrauma and Orthopedic Fixation: A Case Report with Brief Review of Literature.

Introduction: Pyoderma gangrenosum (PG) is a skin condition driven by neutrophil activation resulting in painful ulcers with undermining borders and surrounding erythema. This can be seen, although rarely, post-traumatically. It has been reported in the setting of orthopedic trauma with only 31 cases reported in English literature after orthopedic surgery. Case Report: A 20-year-old Caucasian female presented with multisystem trauma and multiple orthopedic injuries following motor vehicle collision. After fixation of orthopedic injuries, within 1 week post-operatively, the patient began to show signs of wound breakdown characterized by apparent purulence and skin necrosis at surgical sites and subsequently at additional non-surgical sites on bilateral lower extremities. After the failure of aggressive debridement and negative cultures, skin biopsy revealed post-traumatic PG. After diagnosis and treatment with corticosteroid therapy, the patient promptly recovered with the resolution of systemic and musculoskeletal manifestations. Conclusion: Post-traumatic PG should be considered a potential etiology in non-healing wounds with negative cultures. A low threshold for skin biopsy and interdisciplinary involvement should be maintained to expedite diagnosis and guide treatment.

Total hip arthroplasty complications in patients with chronic kidney disease: A comparison study.

Background: It has been noted in the literature that there are increased complication rates following total hip arthroplasty (THA) in patients with chronic kidney disease (CKD) or end stage renal disease (ESRD). However, there is little data directly comparing outcomes in patients undergoing THA for osteoarthritis (OA) versus ESRD or CKD with OA. The objective of this study is to illustrate the risk of developing postoperative complications after THA in the CKD and ESRD populations by stage of disease when compared to a control group (OA) and thus better equip orthopaedic providers in the care of these patients. Methods: The National Inpatient Sample (NIS) was utilized to identify patients undergoing elective THA from 2006 to 2015 with OA, ESRD, and CKD. The prevalence of preoperative comorbidities and the incidence of numerous postoperative complications broken into categories were examined. Results: Between 2006 and 2015 the NIS database reported 4,350,961 patients diagnosed with OA, 8355 diagnosed with ESRD, and 104,313 diagnosed with CKD undergoing THA. The incidence of wound hematoma (2.5% vs. 0.8%; p < .0001), wound infection (0.7% vs. 0.4%; p = .0319), cardiac (1.3% vs. 0.6%; p = .0067), urinary (3.9% vs. 2.0%; p < .0001), and pulmonary complications (2.2% vs. 0.5%; p < .0001) occurred more frequently in patients with OA and ESRD when compared to only OA patients. For patients with OA and CKD, stages 3-5 saw at least half of the complication categories occur at significantly higher rates than OA patients. Conclusion: This study shows that patients with ESRD and CKD have increased rates of complications after THA. This study's specific breakdown by stage and complication can benefit orthopaedic surgeons and practitioners in realistic pre and postoperative planning and provides data that could benefit decision making on bundled reimbursement for this specific patient population, as providers could better account for the postoperative complications noted above and their associated costs.

Are Routine Follow-up Radiographs Necessary for Extra-articular Scapula Body Fractures Managed Conservatively?

INTRODUCTION: Extra-articular scapula body fractures have been shown to have good outcomes with nonsurgical management. What is not known is whether routine postinjury imaging of these fractures is necessary for monitoring healing and alignment. As the shift toward providing cost-effective healthcare continues, we sought to evaluate if routine postinjury imaging of these fractures resulted in any change in management while secondarily evaluating the imaging for fracture patterns at risk of displacement. METHODS: A retrospective review of all extra-articular scapula body fractures managed nonsurgically at our institution was performed from January 2013 to December 2017. We measured the glenopolar angle, lateral border offset, sagittal angulation, and translation on both injury CT scans and follow-up radiographs to evaluate if any displacement occurred. In fractures that displaced more than 10 mm or 10° in any measurement, we evaluated the fracture pattern to see if any particular pattern posed a risk for displacement. In addition, we evaluated the cost of imaging for all radiographs obtained in the follow-up period. RESULTS: A total of 139 patients with 147 extra-articular scapula body fractures were included in our analysis. No patient experienced a change in management based on postinjury radiographs. A total of 120 patients underwent postinjury imaging with a total of 204 radiographic series ordered, equating to $172,769.50 in radiograph expenses. Final radiographs were obtained at an average of 48.4 days postinjury, and overall, no significant difference was observed (P < 0.05) in any radiographic measurement when compared with the initial injury imaging; however, when looking at fractures that displaced, transverse fracture patterns of the scapula body represented a risk factor for displacement (relative risk = 6.5). DISCUSSION: Satisfactory outcomes have previously been demonstrated with nonsurgical management of scapula body fractures and for most of these injuries postinjury imaging may not be necessary or cost effective. LEVEL OF EVIDENCE: Level IV.

Primary Acromioclavicular-Coracoclavicular Reconstruction Using 2 Allografts, TightRope, and Stabilization to the Acromion.

Acromioclavicular (AC) joint injuries are a common cause of shoulder pain, particularly among young athletes participating in contact sports. Injuries to the AC joint most commonly occur from direct impact at the acromion and are classified as types I to VI. Although most AC joint injuries can be treated nonoperatively, types IV to VI are best treated with surgery, with type III being controversial and most surgeons recommending an initial trial of nonoperative treatment. Although numerous surgical techniques have been described, no gold standard technique has been established. Biomechanical testing suggests that anatomic reconstruction of both the AC and coracoclavicular ligaments results in a superior surgical construct. The objective of this Technical Note is to describe our preferred technique for the primary treatment of AC joint instability in the acute and chronic setting. Using 2 free tendon grafts in combination with a cortical button suspensory device combines the advantages of a nonrigid biologic and anatomic AC and coracoclavicular ligament reconstruction while benefiting from the strength of a cortical suspensory device in resisting displacement of the AC joint.

Understanding the Hill-Sachs Lesion in Its Role in Patients with Recurrent Anterior Shoulder Instability.

PURPOSE OF REVIEW: The purpose of this study is to provide an update to the orthopedic field in regard to treatment of the Hill-Sachs lesion and anterior shoulder instability. The review highlights the most current knowledge of epidemiology, clinical evaluation, and surgical methods used to treat Hill-Sachs lesions. It also details the relevant clinical and surgical findings that have been made throughout the literature in the past couple of years. RECENT FINDINGS: The most recent literature covering the Hill-Sachs lesion has focused on the relatively new and unexplored topic of the importance of concomitant injuries while treating a humeral head defect. The glenoid track concept has been clinically validated as a method to predict engagement. 3D-CT has become the "gold standard" for Hill-Sachs imaging; however, it has been noted that 3D-MRI produces results that are not significantly different from CT. Also, it has been found that when the arm is in a position of abduction during the primary injury, there is a higher risk of engagement and subsequent dislocation. Recent studies have demonstrated successful results stemming from purely arthroscopic procedures in treating Hill-Sachs lesions. Anterior shoulder instability, specifically the Hill-Sachs lesion, is an area of orthopedic study that is highly active and constantly producing new studies in an attempt of gaining the best outcomes for patients. The past few years have yielded many excellent discoveries, but there is still much more work to be done in order to fully understand the role of the Hill-Sachs lesion in anterior shoulder instability.