Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery.

This randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

Revision of an unstable hemiarthroplasty or anatomical total shoulder replacement using a reverse design prosthesis.

Instability after arthroplasty of the shoulder is difficult to correct surgically. Soft-tissue procedures and revision surgery using unconstrained anatomical components are associated with a high rate of failure. The purpose of this study was to determine the results of revision of an unstable anatomical shoulder arthroplasty to a reverse design prosthesis. Between 2004 and 2007, 33 unstable anatomical shoulder arthroplasties were revised to a reverse design. The mean age of the patients was 71 years (53 to 86) and their mean follow-up was 42 months (25 to 71). The mean time to revision was 26 months (4 to 164). Pain scores improved significantly (pre-operative visual analogue scale (VAS) of 7.2 (sd 1.6); most recent VAS 2.2 (sd 1.9); p = 0.001). There was a statistically significant increase in mean active forward elevation from 40.2° (sd 27.3) to 97.0° (sd 36.2) (p = 0.001). There was no significant difference in internal (p = 0.93) or external rotation (p = 0.40). Radiological findings included notching in five shoulders (15%) and heterotopic ossification of the inferior capsular region in three (9%). At the last follow-up 31 shoulders (94%) were stable. The remaining two shoulders dislocated at 2.5 weeks and three months post-operatively, respectively. According to the Neer rating system, there were 13 excellent (40%), ten satisfactory (30%) and ten unsatisfactory results (30%). Revision of hemiarthroplasty or anatomical total shoulder replacement for instability using a reverse design prosthesis gives good short-term results.

Anterior shoulder reconstruction: prognostic variables.

To evaluate factors that have prognostic relevance to the outcome of anterior shoulder stabilization procedures, a retrospective review of 282 serial anterior repairs was carried out. All patients were contacted by questionnaire to provide updated outcome information. Twenty-nine patients were lost to follow-up, leaving 253 shoulders in the series. Surgical outcome was based on the Rowe scores derived from the responses to the follow-up survey. At a mean follow-up of 8.7 years, 5 factors were found to have a negative influence on the result of surgery, on the basis of multivariate analysis. These were the presence of a workers' compensation issue, a voluntary instability pattern, a prior instability surgery, shorter periods of postoperative immobilization, and the age of the patient. Factors that were found to have no statistically significant relationship to the result were the sex of the patient, the presence of a Hill-Sachs lesion, the type of instability, the presence of a labral tear, and the experience of the surgeon. Knowledge of these factors can help guide surgical decision making.

Osteonecrosis of the humeral head: results of replacement.

One hundred twenty-seven shoulders treated with replacement arthroplasty for osteonecrosis of the humeral head were reviewed and assessed by mailed questionnaire for results, durability, and complications. These included 71 humeral head replacements and 56 total shoulder replacements. Thirty-six shoulders were lost to follow-up because of death of the patient; an additional 3 shoulders were locking survey follow-up. Thus current follow-up was available for 88 shoulders. At an average follow-up of 8.9 years, subjective improvement was expressed for 70 (79.5%) of the shoulders and no to occasional moderate pain for 68 (77.3%). The mean American Shoulder and Elbow Surgeon score was 63, and the median was 68. Inferior results in American Shoulder and Elbow Surgeon score and range of motion were noted in post-traumatic osteonecrosis, and superior results were noted in steroid-induced osteonecrosis. Little difference was found between humeral head replacement and total shoulder replacement. The most common postoperative complication was rotator cuff tearing, found in 23 (18.1%) of 127 shoulders. This complication was more common in shoulders with a history of any surgery. The cause of osteonecrosis and previous treatment have important implications for the results of shoulder replacement for this disease.

Neurologic complications of surgery for anterior shoulder instability.

Two-hundred eighty-two patients underwent anterior reconstruction for recurrent glenohumeral instability between 1981 and 1991. Twenty-three patients (8.2%) had a neurologic deficit after surgery. Seven had sensory disturbances only; 16 had sensorimotor neuropathies (8 having multiple deficits designated as a diffuse plexopathy and 8 having a more defined deficit in 1 or 2 cords or peripheral nerves). Complete resolution occurred in 18 of the 23 patients. Four patients had a residual deficit (1 patient was lost to follow-up). Three had persistent sensory disturbances; 1 had permanent biceps weakness. None of these patients underwent surgical exploration. Older age (P = .045) and a Bankart lesion (P = .029) were associated with a neurologic complication. At an average follow-up of 8.7 years, 252 patients responded to a questionnaire regarding shoulder outcome, including 20 of the 23 patients with nerve injuries. The difference in the median Rowe score of those with and without nerve injury was not significant (P = .072). Neurologic injuries after anterior shoulder surgery presumably arise as a result of traction. The prognosis for neurologic recovery is generally good. Neurologic injury did not interfere with the outcome of the stabilization procedure.

Osteonecrosis of the humeral head: relationship of disease stage, extent, and cause to natural history.

One hundred fifty-one patients with 200 shoulders affected with osteonecrosis of the humeral head were evaluated for associated factors, the need for prosthetic replacement surgery, the state of the unoperated shoulder, and the existence of prognostic factors. Associated factors included corticosteroid use in 112 shoulders, trauma in 37, Gaucher's disease in 3, sickle cell disease in 3, and radiation necrosis in 1. No cause was evident in 44 shoulders. Ninety-seven shoulders had replacement surgery. The need for replacement surgery was found to be related to extent and stage of humeral head involvement and to diagnosis. Shoulders with a traumatic cause of osteonecrosis required surgery more often (cumulative rate of 77.8% by 3 years). Advancing stage of disease was also related to the need for surgery. By 3 years the cumulative replacement rate was performed in 42% for shoulders with stage 2 disease, 29% with stage 3 disease, 55% with stage 4 disease, and 79% with stage 5 disease. In a similar manner, surgical frequency increased with increasing extent of humeral head involvement. In 60 shoulders not surgically treated that were monitored an average of 8.6 years (range 3.4 to 14.5 years), there was none to occasional moderate pain in 46 and moderate to severe pain in 14. The mean American Shoulder and Elbow Surgeons score was 64.8.

Indications, technique, and results of shoulder arthroplasty in osteonecrosis.

The most common causes of osteonecrosis of the humeral head are steroid use and trauma. Corticosteroids produce osteonecrosis by alterations in fat metabolism, and trauma, by injury to the anterolateral ascending artery. The need for replacement surgery is influenced by stage and extent of the disease, as well as a history of trauma. Results of replacements are superior in steroid-induced osteonecrosis compared to posttraumatic osteonecrosis.

Rotator cuff repair: relevance of patient age.

A review of patients after repair of a rotator cuff tear was done to determine the overall results, the influence of tear size, and the importance of patient age. A total of 88 patients were studied; 53 were 65 years or older, and 35 were younger than 65 years. Tear size was classified as small in three patients, medium in 34, large in 31, and massive in 20. Larger tears were more frequent in the older population. For patients younger than 65 years results were excellent in 31 (88.6%) of 35, satisfactory in three (8.6%), and unsatisfactory in one (2.9%). For those patients older than 65 years results were 41 (77.4%) excellent, seven (13.2%) satisfactory, and five (9.4%) unsatisfactory. Excellent results decreased from 89.2% in small or medium tears to 80.4% in large or massive tears. Although more challenging tears and fewer excellent results can be expected in the older patient, a gratifying outcome can usually be anticipated.

Shoulder arthrography for determination of size of rotator cuff tear.

One hundred eight shoulder arthrograms were performed in 105 patients who subsequently underwent surgical repair of a rotator cuff tear. Eighty-seven were single-contrast arthrograms and 21 were double-contrast studies; three or more views were used for all shoulders. Four readers independently evaluated the arthrograms (two orthopaedic surgeons and two radiologists). The size of the rotator cuff tear could be categorized into one of four groups with accuracy in only 56% of the cases; however, the fear size was identified with accuracy or within one size category in 96% of the shoulders studied.

Metastatic tumors of the foot and ankle.

In a review of the Mayo Clinic files, 17 biopsy-proven cases of metastatic tumors of the foot and ankle were found; 4 additional cases were considered to have metastatic disease on the basis of clinical and radiographic evidence but no histological confirmation was available. Lung, kidney, and colon were the most common sites of the primary tumors. The patients survived as long as 28 months after discovery of the metastasis. Treatment consisted of individualized combinations of orthotics, surgery, and radiotherapy to maintain mobility. In 9 of these 17 cases, no primary lesion was identified at the time the metastasis was diagnosed. Metastatic tumors of the foot present special problems in diagnosis and management.

Pelvic mass causing vesical compression after total hip arthroplasty. Case report.

A 59-year-old woman developed a histiocytic response to methylmethacrylate debris in a loose total hip arthroplasty. This reaction eroded through the medial wall of the acetabulum, producing a pelvic mass and presenting with urinary symptoms. A combination of an abdominal approach for removal of the pelvic mass and a lateral approach for revision of the total hip arthroplasty was required. This condition should be considered in the differential diagnosis of a mass adjacent to a loose prosthesis.

Subjective results of hallux rigidus following treatment with cheilectomy.

The records of 58 patients who had hallux rigidus and were treated with cheilectomy between 1977 and 1984 showed the following results: 53.4% completely satisfactory, 19% mostly satisfactory, 27.6% unsatisfactory. No deterioration of results with time was apparent. When the results were analyzed in relation to the degenerative changes that were evident in the preoperative roentgenograms, the failure rate was increased from 15% with Grade I changes to 37.5% with Grade III changes. Cheilectomy is the procedure of choice in patients with hallux rigidus and Grade I changes.

Delayed neural reconstruction in the lower extremity: results of interfascicular nerve grafting.

During a 4-year period, one of the authors (M.B.W.) performed 16 nerve reconstructions by interfascicular grafting in the lower extremities of 13 patients. Three patients were excluded from the study: one was lost to follow-up and two had less than 1-year follow-up. At an average follow-up of 30 months, the results of 13 procedures in 10 patients were evaluated. Results were good after five procedures, fair after five, and poor after three. Superior results were evident with shorter graft lengths and after nerve transection injuries.

A review of ruptures of the Achilles tendon.

Rupture of the Achilles tendon is a relatively infrequent injury that is often missed by the initial treating physician. The diagnosis can be established on the basis of the physical examination with weakness of plantarflexion, a palpable gap in the tendon, and a positive squeeze test. Special diagnostic studies are rarely necessary. In the majority of cases, the etiologic basis for the rupture appears to be a combination of intratendon degeneration and mechanical stress. Conservative treatment of an acute rupture by immobilization with a cast provides satisfactory results. For the younger, more athletic patient, surgical repair should be considered.

Chevron osteotomy: analysis of factors in patients' dissatisfaction.

The results of all Chevron osteotomies for hallux valgus performed at the Mayo Clinic between January 1976 and June 1982 were reviewed at least 1 year after surgery. Of the total 157 patients with 228 operations eligible for inclusion in this study, 154 patients with 225 operations were interviewed. Complete satisfaction was expressed for 79.1% of the procedures, satisfaction with minor reservations for 12.9%, and dissatisfaction for 8%. For the osteotomies producing incomplete satisfaction, further investigation identified failure to achieve correction and technical errors as the most prominent factors. There were no cases of avascular necrosis, osteotomy nonunion, or hallux varus.