Glenoid damage from articular protrusion of metal suture anchor after arthroscopic rotator cuff repair.

Arthroscopic repair of rotator cuff tears has been shown to be effective and safe. The use of suture anchors has increased the ability to perform rotator cuff repairs arthroscopically. However, the use of suture anchors for any surgery around the shoulder can result in complications if the devices are not used and inserted properly. Complications that have been reported with the use of suture anchors for rotator cuff surgery include prominent anchors in the tuberosities, dislodged anchors secondary to pull-out or improper insertion, and osteolysis around the anchors. We report a case of articular cartilage damage secondary to a suture anchor protruding through the humeral head because of improper anchor insertion. Our patient's case reminds surgeons not only to be careful of the depth of insertion of suture anchors when performing rotator cuff surgery but also to obtain radiographs to evaluate the anchor position if patients continue to have symptoms after rotator cuff repair using these devices.

Upper-extremity thrombosis in a patient after biceps tenodesis.

Deep venous thrombosis (DVT) of the upper extremity is uncommon compared with DVT of the lower extremity. Exertional DVT has been described in some athletes, especially in the dominant arm of baseball players. It is important for health care professionals to recognize the signs and symptoms of upper-extremity DVT, which can occur after exertion or after surgery of the upper extremity. Superficial venous thrombosis is also very uncommon in the upper extremity. This article describes a case of superficial venous thrombosis that mimicked DVT in the surgical (right) arm of a recreational baseball player after suprapectoral biceps tenodesis for a painful superior labrum anterior-posterior lesion. Although the superficial venous system of the upper arm has frequent connections to the deeper basilar system, it is uncommon for superficial venous thrombosis to occur concurrently with DVT. It is important for clinicians to understand the distinction between superficial venous thrombosis and DVT in the upper extremity because the physical findings, treatment, and prognosis for these 2 entities differ in the following ways: (1) superficial venous thrombosis may be accompanied by a cord, but DVT is associated with more generalized swelling; (2) superficial venous thrombosis requires symptomatic treatment only, whereas DVT requires anticoagulation; and (3) superficial venous thrombosis typically resolves with few sequelae, whereas upper-extremity DVT increases the risk of future DVT.

Does preoperative American Society of Anesthesiologists score relate to complications after total shoulder arthroplasty?

BACKGROUND: For hip and knee arthroplasties, an American Society of Anesthesiologists (ASA) score greater than 2 is associated with an increased risk of medical and surgical complications. No study, to our knowledge, has evaluated this relationship for total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (reverse TSA). QUESTIONS/PURPOSES: We aimed to assess the relationship between the ASA score and (1) surgical complications, (2) medical complications, and (3) hospitalization length after TSA, reverse TSA, and revision arthroplasty. METHODS: We retrospectively analyzed all patients who had undergone TSAs, reverse TSAs, or revision arthroplasties by the senior author (EGM) from November 1999 through July 2011 who had at least 6 months' followup. Of the 485 procedures, 452 (93.2%) met the inclusion criteria. Data were collected on patient demographics, comorbidities, hospitalization length, and short-term (≤ 6 months) medical and surgical complications. Logistic regression analysis modeled the risk of having postoperative complications develop as a function of the ASA score. RESULTS: Patients with an ASA score greater than 2 had a greater risk of having a surgical complication develop (p < 0.001; OR, 2.27; 95% CI, 1.36-3.70) and three times the risk of prosthesis failure (ie, component dislocation, component loosening, and hardware failure) (p < 0.001; OR, 3.23; 95% CI, 1.54-6.67). Higher ASA scores were associated with prolonged length of hospitalization (effect size 0.46, p < 0.001), but not medical complications. CONCLUSIONS: ASA score is associated with surgical, but not medical, complications after TSA and reverse TSA. The ASA score could be used for risk assessment and preoperative counseling. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Impingement is not impingement: the case for calling it "Rotator Cuff Disease".

Historically, many causes have been proposed for rotator cuff conditions. The most prevalent theory is that the rotator cuff tendons, especially the supraspinatus, make contact with the acromion and coracoacromial ligament, resulting in pain and eventual tearing of the tendon. However, more recent evidence suggests that this concept does not explain the changes in rotator cuff tendons with age. The role of acromioplasty and coracoacromial ligament release in the treatment of rotator cuff disease has become questioned. Evidence now suggests that tendinopathy associated with aging may be a predominant factor in the development of rotator cuff degeneration. We propose that the overwhelming evidence favors factors other than "impingement" as the major cause of rotator cuff disease and that a paradigm shift in the way the development of rotator cuff pathology is conceptualized allows for a more comprehensive approach to the care of the patient with rotator cuff disease.

A survey of current policy and practice of surgical exposure for preclerkship medical students at American medical institutions.

BACKGROUND: The goals of this study were to (1) determine the extent of preclerkship surgical participation in American medical colleges; (2) examine policies regarding such surgical participation; and (3) elicit medical school administrators' perceptions about such exposure. METHODS: Surveys were sent to 128 accredited medical schools (1 administrator each). The 54 (42%) replies were analyzed using descriptive statistics and Student's t tests, with significance defined as a P value of ≤ .05. RESULTS: Of the respondents, 55.6% did not permit student surgical participation. Only 22.2% of responding institutions offered preclerkship surgical skills electives. Administrators from the former group of schools perceived significantly greater risk (P = .001) to patient safety with student surgical participation than did administrators at schools permitting such participation, even though no respondents reported malpractice or worker's compensation cases arising from student participation. CONCLUSIONS: Medical students have limited opportunities for preclerkship surgical participation at most American medical institutions, possibly because of unsubstantiated concerns for patient safety.

Proximal biceps tendon tear in an adolescent tennis player.

The diagnosis of a torn biceps tendon in athletes who use overhead throwing or swinging motions can be difficult to make because there is no one physical examination finding that will confirm the diagnosis, and because magnetic resonance imaging, although sometimes helpful, does not image the length of the biceps tendon adequately. We report a case of an isolated partial biceps tendon tear in an adolescent female athlete who was diagnosed during arthroscopy after the tendon was pulled into the joint. The tendon was cut and a tenodesis was performed. Two years after the surgical procedure, the patient was without pain and returned to playing tennis at her previous level.

Postoperative death associated with a reverse prosthesis.

The mortality rate after total shoulder arthroplasty, and specifically after reverse total shoulder arthroplasty, has not received much attention in the literature. Although complications of the reverse total shoulder arthroplasty are well known, fatalities secondary to complications related to the unique features of the reverse prosthesis have not, to our knowledge, been previously reported. We report the case of an elderly man who developed shoulder instability after the implantation of a reverse prosthesis followed by disassociation of the glenosphere from the baseplate. After a reoperation to revise and reassemble the components, he developed an infected shoulder and sepsis, and subsequently died from the complications of sepsis. This death represents a perioperative mortality rate of 0.5% in our series of 190 cases. The mortality rate after reverse total shoulder seems to be similar to that after standard total shoulder arthroplasty.

Recovery from ischemic acute kidney injury by spironolactone administration.

BACKGROUND: Prophylactic mineralocorticoid receptor (MR) antagonism with spironolactone (Sp) in rats completely prevents renal damage induced by ischemia. Because acute renal ischemia cannot typically be predicted, this study was designed to investigate whether Sp could prevent renal injury after an ischemic/reperfusion insult. METHODS: Six groups of male Wistar rats were studied: rats that received a sham abdominal operation (S); rats that underwent 20 min of ischemia and reperfusion for 24 h (I/R) and four groups of rats treated with Sp (20 mg/kg) 0, 3, 6 or 9 h after ischemia. RESULTS: As expected, I/R resulted in renal dysfunction characterized by a fall in renal blood flow and glomerular filtration rate and severe tubular injury which was confirmed by a significant increase in tubular damage biomarkers including kidney injury molecule-1, heat shock protein 72 and urinary protein excretion. The renal injury induced by I/R was in part due to Rho-kinase, endothelin and angiotensin II type 1 receptor upregulation. Interestingly, Sp administration at 0 and 3 h after ischemia completely reversed and prevented the damage induced by I/R. The protection induced by Sp given 6 h after ischemia was partial, but no protection was observed by administering Sp 9 h after ischemia. CONCLUSION: Our results show that MR antagonism administered, either immediately or 3 h after I/R, effectively prevented ischemic acute renal injury, indicating that spironolactone is a promising agent for preventing acute kidney injury once an ischemic insult has occurred.

Complications of the reverse prosthesis: prevention and treatment.

Reverse total shoulder arthroplasty was developed in the late 1980s for elderly patients with rotator cuff arthropathy. Several biomechanical advantages of the reverse shoulder arthroplasty result in improved deltoid function, which improves shoulder motion and function compared to other types of shoulder arthroplasty. The main indication for the reverse prosthesis is painful rotator cuff tear arthropathy. The indications for reverse shoulder arthroplasty have continued to expand since it was first performed in the United States in 2004. Although the results of reverse total shoulder arthroplasty have been generally favorable, the complication rate is higher than that of conventional total shoulder arthroplasty. Complications include those common to other shoulder procedures (infection, instability, and nerve injury) and those unique to reverse total shoulder arthroplasty (scapular notching, glenoid baseplate failure, component disassociation, and scapular stress fractures). It is helpful for orthopaedic surgeons to understand ways to avoid these complications and methods with which to treat them.

Intraarticular abnormalities in overhead athletes are variable.

BACKGROUND: The cause of shoulder pain and dysfunction in the overhead athlete can be variable. Several studies illustrate the wide variety of lesions seen at the time of arthroscopy in overhead athletes who require surgery but it is unclear whether these differ by sport. QUESTIONS/PURPOSES: We examined overhead athletes with shoulder dysfunction to determine (1) the range of arthroscopically visualized shoulder abnormalities with specific attention to the posterosuperior glenohumeral joint and the rotator cuff; and (2) the relationship of sport type to these abnormalities. METHODS: We reviewed our institution's database for professional and collegiate athletes in overhead sports who, from 1996 through 2010, had diagnostic shoulder arthroscopy for insidious, nontraumatic, persistent pain and inability to participate in their sport. A descriptive analysis of the arthroscopic findings from 51 consecutive patients (33 males, 18 females; mean age, 25 years; range, 15-59 years) was done. We analyzed the arthroscopic findings with respect to sport using analysis of variance and Fisher's exact test. RESULTS: There was a wide range of superior labrum, posterosuperior glenoid, and rotator cuff abnormalities. Overall, the most frequent abnormalities were posterosuperior glenohumeral joint changes. Swimmers had fewer intraarticular abnormalities than baseball players. CONCLUSIONS: We found a wide spectrum of intraarticular abnormalities in the shoulder of overhead athletes with shoulder pain requiring surgery. Additional study is needed to determine whether these abnormalities or combinations relate to specific athletic movements. LEVEL OF EVIDENCE: Level IV, retrospective case series. See Guidelines for Authors for a complete description of levels of evidence.

First-rib stress fracture in a high-school lacrosse player: a case report and short clinical review.

A 14-year-old right-hand dominant female lacrosse player presented with a complaint of right shoulder and upper posterior thorax pain of 8 days' duration. She had been playing lacrosse at the attack wing and midfielder positions and experienced insidious pain after a game. She had no history of trauma to that shoulder during that game and had not experienced an injury in the past. Six days after the pain developed, she woke up one night with a sudden increase in the pain, which brought her to tears and caused slight difficulty with breathing. The pain was located anteriorly just lateral to the right sternoclavicular joint and posteriorly in the paraspinal muscles in the upper thoracic region. Physical examination suggested a first-rib stress fracture, which was subsequently confirmed by chest and shoulder radiographs.

Clinical and diagnostic tests for shoulder disorders: a critical review.

The shoulder is one of the most complex joints in the human body and, as such, presents an evaluation and diagnostic challenge. The first steps in its evaluation are obtaining an accurate history and physical examination and evaluating conventional radiography. The use of other imaging modalities (eg, ultrasound, magnetic resonance imaging and computed tomography) should be based on the type of additional information needed. The goals of this study were to review the current limitations of evidence-based medicine with regard to shoulder examination and to assess the rationale for and against the use of diagnostic physical examination tests.

Clinical and imaging assessment for superior labrum anterior and posterior lesions.

In the evaluation of the painful shoulder, especially in the overhead athlete, diagnosing superior labrum anterior and posterior (SLAP) lesions continues to challenge the clinician because of 1) the lack of specificity of examination tests for SLAP; 2) a paucity of well-controlled studies of those tests; and 3) the presence of coexisting confounding abnormalities. Some evidence indicates that multiple positive tests increase the likelihood that a SLAP lesion is present, but no one physical examination finding conclusively makes that diagnosis. The goals of this article were to review the physical examination techniques for making the diagnosis of SLAP lesions, to evaluate the clinical usefulness of those examinations, and to review the role of magnetic resonance imaging in making the diagnosis.