Evaluation and treatment of failed shoulder instability procedures.

Management of the unstable shoulder after a failed stabilization procedure can be difficult and challenging. Detailed understanding of the native shoulder anatomy, including its static and dynamic restraints, is necessary for determining the patient's primary pathology. In addition, evaluation of the patient's history, physical exam, and imaging is important for identifying the cause for failure after the initial procedure. Common mistakes include under-appreciation of bony defects, failure to recognize capsular laxity, technical errors, and missed associated pathology. Many potential treatment options exist for revision surgery, including open or arthroscopic Bankart repair, bony augmentation procedures, and management of Hill Sachs defects. The aim of this narrative review is to discuss in-depth the common risk factors for post-surgical failure, components for appropriate evaluation, and the different surgical options available for revision stabilization. Level of evidence Level V.

WITHDRAWN: Stemless humeral component in total shoulder arthroplasty: 2-year age-related clinical outcomes.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Rotator cuff rehabilitation: current theories and practice.

A fully functioning, painless shoulder joint is essential to maintain a healthy, normal quality of life. Disease of the rotator cuff tendons (RCTs) is a common issue that affects the population, increasing with age, and can lead to significant disability and social and health costs. RCT injuries can affect younger, healthy patients and the elderly alike, and may be the result of trauma or occur as a result of chronic degeneration. They can be acutely painful, limited to certain activities or completely asymptomatic and incidental findings. A wide variety of treatment options exists ranging from conservative local and systemic pain modalities, to surgical fixation. Regardless of management ultimately chosen, physiotherapy of the RCT, rotator cuff muscles and surrounding shoulder girdle plays an essential role in proper treatment. Length of treatment, types of therapy and timing may vary if therapy is definitive care or part of a postoperative protocol. Allowing time for adequate RCT healing must always be considered when implementing ROM and strengthening after surgery. With current rehabilitation methods, patients with all spectrums of RCT pathology can improve their function, pain and quality of life. This manuscript reviews current theories and practice involving rehabilitation for RCT injuries.

Long head biceps tenodesis with a knotless cinch suture anchor: a biomechanical analysis.

PURPOSE: The purpose of this study was to evaluate the initial fixation strength of 3 techniques of arthroscopic tenodesis of the long head of the biceps (LHB). METHODS: Eighteen human cadaveric shoulders were randomly assigned to one of 3 simulated arthroscopic biceps tenodesis techniques-simple suture (SS), Krakow stitch (KS), or lasso loop (LL)-combined with a knotless fixation implant (3.5-mm Piton Anchor; Tornier, Minneapolis, MN). Biomechanical parameters were evaluated by cyclic loading and load to failure. RESULTS: The mean failure load (P = .007) was 158.3 ± 32.2 N, 109.8 ± 41.1 N, and 46.6 ± 3.8 N for the KS, SS, and LL techniques, respectively. Mean stiffness was greater (statistically significant) in the KS (21.4 ± 3.0 N/mm) and SS (20.7 ± 7.9 N/mm) treatment groups compared with the LL group (4.5 ± 1.5 N/mm) (P = .011). CONCLUSIONS: Biceps tenodesis performed with a more secure tendon suturing technique, such as the Krakow technique, provides superior ultimate and fatigue strength and thus may be more secure in clinical application and yield better clinical results. The mechanical properties of the LL technique were especially poor in comparison. CLINICAL RELEVANCE: Although more complex suturing techniques for arthroscopic biceps tenodesis can be technically challenging, more secure tendon fixation may improve clinical outcomes.

Eikenella corrodens septic hip arthritis in a healthy adult treated with arthroscopic irrigation and debridement.

We present the case of a seemingly spontaneous septic hip arthritis in a patient with no pertinent medical history. Our patient presented with persistent and worsening sharp lower back pain and underwent arthrocentesis of the hip joint, yielding purulent fluid positive for Eikenella corrodens. Our patient's treatment consisted of arthroscopic irrigation with debridement and limited synovectomy that used a supine 2-incision technique. To our knowledge, this is the first reported case of an E corrodens septic hip arthritis.

The global percutaneous shuttling technique tip for arthroscopic rotator cuff repair.

Most arthroscopic rotator cuff repairs utilize suture passing devices placed through arthroscopic cannulas. These devices are limited by the size of the passing device where the suture is passed through the tendon. An alternative technique has been used in the senior author's practice for the past ten years, where sutures are placed through the rotator cuff tendon using percutaneous passing devices. This technique, dubbed the global percutaneous shuttling technique of rotator cuff repair, affords the placement of sutures from nearly any angle and location in the shoulder, and has the potential advantage of larger suture bites through the tendon edge. These advantages may increase the area of tendon available to compress to the rotator cuff footprint and improve tendon healing and outcomes. The aim of this study is to describe the global percutaneous shuttling (GPS) technique and report our results using this method. The GPS technique can be used for any full thickness rotator cuff tear and is particularly useful for massive cuff tears with poor tissue quality. We recently followed up 22 patients with an average follow up of 32 months to validate its usefulness. American Shoulder and Elbow Surgeons scores improved significantly from 37 preoperatively to 90 postoperatively (P<0.0001). This data supports the use of the GPS technique for arthroscopic rotator cuff repair. Further biomechanical studies are currently being performed to assess the improvements in tendon footprint area with this technique.

Gluteus medius strengthening and the use of the Donatelli Drop Leg Test in the athlete.

OBJECTIVES: To evaluate and strengthen the posterior segment of the gluteus medius. DESIGN: A technical description of a novel examination and rehabilitation protocol. SETTING: The gluteus medius, primarily a hip abductor, serves several important functions in the athlete. Weakness of the gluteus medius has been linked to injuries in the shoulder and iliotibial band, as well as ankle instability. Though previously treated as a homogenous muscle, recent studies of the gluteus medius show three segments with distinct function and activation - the anterior, middle, and posterior. Current rehabilitation protocol focuses primarily on the anterior and middle segments, neglecting the posterior. CONCLUSION: We propose a three-stage protocol for strengthening and rehabilitation of the injured athlete and the Drop Leg Test, which can be used to identify weakness in the posterior segment of the gluteus medius.

Osteosarcoma cells differentiate into phenotypes from all three dermal layers.

BACKGROUND: Osteosarcomas are the most common solid malignant bone tumors, but little is known of their origin. The embryonal rest hypothesis views cancer cells as arising from committed progenitor stem cells in each tissue. Adult tissue contains primitive stem cells that retain the ability to differentiate across dermal lines, raising the possibility that the stem cell of origin of cancers may be from a more primitive stem cell than a progenitor. QUESTIONS/PURPOSES: Can osteosarcoma cells, when cultured under conditions used for multipotent stem cells, be induced to differentiate into multiple phenotypes, including those of the three different dermal lineages: mesodermal, ectodermal, and endodermal? METHODS: One rat and one human osteosarcoma cell line were cultured and treated with concentrations of 0, 10(-10), 10(-9), 10(-8), 10(-7), and 10(-6) mol/L dexamethasone for 5 weeks. Seventeen phenotypes were assayed either by tissue-specific histochemical stains or antibodies to tissue-specific proteins. Each phenotype was tested across all dexamethasone concentrations for each cell line and each phenotype was tested in three separate experiments with induction by dexamethasone RESULTS: Rat osteosarcoma (ROS) 17/2.8 and human osteosarcoma cell line U-2 show the appearance of cells that have markers for (1) mesodermal phenotypes such as bone, cartilage, skeletal muscle, and endothelial cells, (2) ectodermal phenotypes such as astrocytes, oligodendrocytes, neurons, and keratinocytes, and (3) an endodermal phenotype, hepatocytes. This indicates osteosarcomas are composed, at least in part, of primitive stem cells capable of differentiating into tissues from all three dermal lineages. CLINICAL RELEVANCE: If osteosarcomas arise from primitive stem cells, then treatment of osteosarcomas with exogenous differentiation agents may cause the stem cells to differentiate, thus halting their proliferation and stopping tumor growth.