Tendon transfer for trapezius palsy.

The trapezius muscle produces upward scapular rotation that in turn allows complete lateral elevation (abduction) by maintaining the acromiohumeral distance and the deltoideus resting length. Loss of trapezius function leads to shoulder drooping, loss of scapular external rotation with secondary loss of abduction. When conservative treatment has failed and in cases where nerve surgery is not indicated, the most common procedure for treating this condition is the Eden-Lange (EL) procedure. This procedure entails transferring the levator scapulae (LS) to the lateral part of the scapular spine, and the rhomboid major (RM) and minor (Rm) to the infraspinatus fossa to restore the lost trapezius function. Recently, Elhassan et al. proposed a modification of the original EL procedure to recreate the line of pull of the different parts of the trapezius muscle. The modified transfer may yield successful outcomes in patients with trapezius paralysis who failed to improve after well-conducted conservative treatment. Longer follow-up is needed to confirm the stability of the good outcomes of this reconstruction.

Biomechanical bases for tendon transfers at the shoulder.

Paralysis of the muscles around the shoulder is a debilitating condition that continues to be a very challenging problem. It leads to an inability to position one's hand in space. This greatly compromises the function of the upper limb and can lead to chronic shoulder pain due to inferior glenohumeral subluxation. Management of these complex problems has two main objectives: (i) stabilize the glenohumeral joint to decrease pain related to inferior glenohumeral subluxation; (ii) restore active range of motion in external rotation, abduction, and internal rotation. All the shoulder muscles contract in a coordinated and complex manner to allow the shoulder to move through a complete range of motion. Understanding how the different muscle groups coordinate their contractions and the basic biomechanical principles of tendon transfers is paramount before considering doing a tendon transfer around the shoulder. To function properly, a tendon transfer should have a similar line of pull (similar moment arm), similar tension and similar excursion to that of the muscle it replaces; one tendon transfer should replace only one function and the donor (transferred) muscle should have normal muscle strength (at least M4).

Triple-bundle anatomical reconstruction using the coracoacromial ligament and the short head of biceps tendon to stabilize chronic acromioclavicular joint dislocations: A cadaver feasibility study.

INTRODUCTION: In cases of chronic acromioclavicular joint separation, the biomechanical properties of anatomical reconstructions are closer to the native configuration than the Weaver-Dunn procedure. Consequently, the radiological and clinical outcomes are better. However, an additional incision is needed to harvest the graft, which increases the procedure's morbidity. HYPOTHESIS: Triple-bundle reconstruction can be performed with the coracoacromial ligament (CAL) and the semi conjoined tendon (SCT). MATERIAL AND METHODS: Bilateral dissection was performed on the upper limb of six fresh-frozen cadavers. Measurements useful to the procedure were taken on one limb, specifically the minimum graft length needed and the available length. The surgical procedure was performed on the other limb. The proximally based SCT was passed through the base of the coracoid process, then divided into two strips tightened from the superior aspect of the coracoid process to the clavicular insertion points of the conoid and trapezoid ligaments. The CAL was detached from the coracoid process and then secured in the medullary canal of the clavicle, after its lateral one-quarter was resected (i.e., 10mm). RESULTS: The mean length of the SCT was 101.7±7.6mm (95.1-114.5) and the mean length of the CAL was 35.3±4.7mm (28.7-42.5). The SCT length needed for this reconstruction was 58±4.3mm (51.5-62) medially and 60.3±4.6mm (54.3-66.3) laterally. The procedure was feasible in all six cadavers with an average excess length of 39.9±5.7mm (32.2-47) for the conoid bundle, 37.6±5mm (31-45.1) for the trapezoid ligament and 6±2.7mm (3-9.5) for the CAL. DISCUSSION: Triple-bundle anatomical reconstruction using the SCT and CAL is feasible. However, the strength of this construct must be evaluated biomechanically before it can be used clinically. LEVEL OF EVIDENCE: Not applicable - cadaver study.

Shoulder function in patients with deltoid paralysis and intact rotator cuff.

INTRODUCTION/HYPOTHESIS: The purpose of this study is to determine the mid/long term shoulder function in patients with complete deltoid paralysis and intact rotator cuff. 27 patients with at least 2-years FU were included. MATERIALS AND METHODS: Outcome measures included pain, range of motion (including the swallowtail test STT), deltoid extension lag test DELT and Bertelli test), subjective fatigability using the injured shoulder and postoperative modified Neer ratings. RESULTS: At an average 68 months FU, mean shoulder abduction was 131°, flexion 153°, external rotation with the arm at the side 58° and 58° with the arm abducted. All patients reported quick fatiguability with repetitive use of the injured arm which did not change over time. Average pain score was 2. Eighteen patients had positive STT and DELT tests and all patients had positive Bertelli test. DISCUSSION: This study demonstrates that patients with deltoid paralysis and intact rotator cuff do maintain most of their shoulder function and this is sustained over time. LEVEL OF EVIDENCE: Level IV; prognostic Study: case series.

Ulnar head replacement and sigmoid notch resurfacing arthroplasty with a lateral meniscal allograft: 'calamari procedure'.

We report the outcomes of ulnar head replacement with concomitant resurfacing of the sigmoid notch with a lateral meniscal allograft that attempted to recreate the palmar and dorsal radioulnar ligaments in four patients. Patients' ranges of motion, grip strength, postoperative complications and radiographs were assessed. The mean follow-up was 20 (range 12-28) months. There was an increase in postoperative range of motion with an average increase in grip strength of 43% to the unaffected extremity. All patients experienced marked reduction in their postoperative pain. No patients reported symptoms of implant instability. Distal ulna implant arthroplasty with a lateral meniscal allograft gives favourable short-term outcomes. LEVEL OF EVIDENCE: IV.

Long-term outcomes of cemented versus cementless humeral components in arthroplasty of the shoulder: a propensity score-matched analysis.

AIMS: In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder. PATIENTS AND METHODS: All patients who underwent primary arthroplasty of the shoulder at our institution between 1970 and 2012 were included in the study. There were 4636 patients with 1167 cemented humeral components and 3469 cementless components. Patients with the two types of fixation were matched for nine different covariates using a propensity score analysis. A total of 551 well-balanced pairs of patients with cemented and cementless components were available after matching for comparison of the outcomes. The clinical outcomes which were analysed included loosening of the humeral component determined at revision surgery, periprosthetic fractures, post-operative infection and operating time. RESULTS: The overall five-, ten-, 15- and 20-year rates of survival were 98.9%, 97.2%, 95.5%, and 94.4%, respectively. Survival without loosening at 20 years was 98% for cemented components and 92.4% for cementless components. After propensity score matching including fixation as determined by the design of the component, humeral loosening was also found to be significantly higher in the cementless group. Survival without humeral loosening at 20 years was 98.7% for cemented components and 91.0% for cementless components. There was no significant difference in the risk of intra- or post-operative fracture. The rate of survival without deep infection and the mean operating time were significantly higher in the cemented group. CONCLUSION: Both types of fixation give rates of long-term survival of > 90%. Cemented components have better rates of survival without loosening but this should be weighed against increased operating time and the risk of bony destruction of the proximal humerus at the time of revision of a cemented humeral component. Cite this article: Bone Joint J 2017;99-B:666-73.

Modified percutaneous trigger finger release.

Stenosing tenosynovitis or trigger finger is one of the most common disorders that affect the flexor tendon apparatus of the hand. Percutaneous release has been previously reported to be easier, quicker, less invasive and less costly than open surgery. The purpose of this study was to report the outcome of an alternative percutaneous trigger finger release technique. From March 2008 to January 2014, 92 patients (128 fingers) who underwent the alternative percutaneous trigger finger release, with a minimum of 6 months follow-up were included. Outcomes included size of skin incision, pain, residual symptoms, satisfaction and complications. Percutaneous release was achieved in all fingers, except 1 for which an opening of the skin was necessary to complete the release of the pulley. Eight fingers (6%) required revision open surgery because of persistence of their symptoms. At 1 week after the procedure, no finger swelling was reported, however 4 fingers (3%) were painful and 45 (35%) were stiff and required physiotherapy. Percutaneous release was successful in 120 fingers (94%). At the final follow-up, all the patients were satisfied by the procedure (95 rated their result as much better and 32 as better). This study shows that our alternative percutaneous trigger finger release is a reliable and safe procedure with high patient satisfaction. LEVEL OF EVIDENCE: Level IV, clinical study, therapeutic study.

Factors associated with improved outcomes following proximal row carpectomy: a long-term outcome study of 144 patients.

UNLABELLED: We conducted a review of 144 consecutive patients who underwent proximal row carpectomy from 1967 to 2010 for the diagnosis of wrist arthritis. At a mean follow-up of 13.4 years, patients experienced good pain relief with preservation (but not improvement) of wrist motion. A total of 17 patients (12%) required revision surgery at an average of 44.6 months. Improved pain, function, and survival outcomes were seen in those who underwent proximal row carpectomy after the age of 40, had a preoperative diagnosis of Kienbock's disease, who underwent a concomitant neurectomy procedure, patients who were non-labourers, and patients who underwent surgery after 1990. Although 45% of patients developed moderate to severe radiocapitate arthrosis postoperatively, these findings did not correlate with clinical outcomes or risk of revision surgery. Patients with type II lunate and type II and III capitate shapes had higher rates of postoperative radiocapitate arthrosis. LEVEL OF EVIDENCE: III, Prognostic.

A comparison of single-versus double-row suture anchor techniques in a simulated repair of the rotator cuff: an experimental study in rabbits.

We compared time-dependent changes in the biomechanical properties of single-and double-row repair of a simulated acute tear of the rotator cuff in rabbits to determine the effect of the fixation techniques on the healing process. A tear of the supraspinatus tendon was created in 80 rabbits which were separated into two equal groups. A single-row repair with two suture anchors was conducted in group 1 and a double-row repair with four suture anchors in group 2. A total of ten intact contralateral shoulder joints was used as a control group. Biomechanical testing was performed immediately post-operatively and at four and eight weeks, and histological analysis at four and eight weeks. The mean load to failure in group 2 animals was greater than in group 1, but both groups remained lower than the control group at all intervals. Histological analysis showed similar healing properties at four and eight weeks in both groups, but a significantly larger number of healed tendon-bone interfaces were identified in group 2 than in group 1 at eight weeks (p < 0.012). The ultimate load to failure increased with the number of suture anchors used immediately post-operatively, and at four and eight weeks. The increased load to failure at eight weeks seemed to be related to the increase in the surface area of healed tendon-to-bone in the double-row repair group.

Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: does it work?

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis. At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively. Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of pectoralis major, particularly if there is pre-operative anterior subluxation of the humeral head.

Metastasis of squamous-cell carcinoma of the lung to the first web space of the hand.

While primary squamous-cell carcinoma of the hand is common, metastasis of a squamous-cell carcinoma to the hand is very rare. It has been reported to arise from carcinoma of the lung and oesophagus and, rarely, from other tumours. We describe a patient with metastatic squamous-cell carcinoma occurring in the first web space of the hand from primary lung cancer, which remained undetected for 30 months after treatment of the metastasis.

Ultrasonography for the evaluation of forearm interosseous membrane disruption in a cadaver model.

Recognition of interosseous membrane disruption associated with radial head injury and Essex-Lopresti injury is important, especially if radial head excision is contemplated. Because a widely accepted method to diagnose interosseous membrane disruption does not exist, we evaluated the accuracy of ultrasonography to diagnose this injury in a cadaver model. Nine pairs of cadaver forearms were randomized into 2 groups. The central third of the interosseous membrane of forearms of group 1 was cut, whereas it was visualized but not cut in group 2. A dynamic ultrasound examination was performed to determine interosseous membrane integrity, and static images were made. The static images were evaluated by 2 other radiologists and interpretations were recorded. One radiologist incorrectly interpreted 1 pair of forearms; the other 2 radiologists were 100% accurate. The accuracy of ultrasonography in detecting interosseous injuries was 96% with our methods.

Rectus abdominis free-tissue transfer in lower extremity reconstruction: review of 40 cases.

Forty patients who underwent rectus abdominis free-tissue transfer with split-thickness skin grafts for reconstruction of the lower extremity are reported. The procedures were performed between January, 1992 and December, 1998. Transfers were utilized for coverage of acute soft-tissue and bone defects (18 patients), defects following radical debridement of chronic osteomyelitis of the leg and foot (13 patients) or diabetic foot ulcers (eight patients), and for unstable scars (one patient). At a mean follow-up of 3.6 years, there was no donor-site morbidity; there were seven local complications--five superficial flap necroses and two flap congestions. Three flaps were totally lost. All patients but one were ambulatory and fully weight-bearing at the time of review, with consolidation of the fractures and bone defects and no evidence of recurrence of infection in the osteomyelitis or diabetic foot ulcer groups. The relatively high success rate (92.5 percent), the ease of surgical dissection, the consistency and size of the deep inferior epigastric pedicle, the absence of donor-site morbidity, and relatively low complication rates make the rectus abdominis muscle one of the preferable free-tissue transfers for these authors.

Microvascular composite tissue transfer for the management of type IIIB and IIIC fractures of the distal leg and compound foot fractures.

Patients who sustain high-energy, compound fractures with severe contamination and soft tissue loss, face high rates of delayed union, nonunion, infection and, in some instances, amputation. The authors reviewed 18 patients with compound foot fractures and IIIB and IIIC tibial fractures. All patients were treated by early free-flap coverage and simultaneous bone reconstruction. Corticocancellous bone grafting, composite osteocutaneous free flaps, or bone transport techniques were utilized, as required. Bony union was achieved in all cases; rehabilitation and return to work occurred within 12 to 18 months, with no major complications. The authors believe that the reconstruction ladder usually followed should be altered in certain cases in which severe periosteal stripping and soft-tissue contamination necessitate distant free composite tissue transfer, particularly those cases involving the distal third of the leg and foot. Simultaneous reconstruction is superior to other methods of wound management in providing early coverage of extensive wounds, a barrier against bacterial contamination, prevention of osteomyelitis, and enhanced union of the fractures.