Capsular needle biopsy as a pre-operative diagnostic test for peri-prosthetic shoulder infection.

BACKGROUND: Establishing the diagnosis of peri-prosthetic shoulder infection prior to revision shoulder arthroplasty can be difficult. The objectives of the present study were (i) to describe the technique of fluoroscopic capsular needle biopsy for the diagnosis of peri-prosthetic shoulder infection and (ii) to determine the feasibility and preliminary accuracy of the test in a pilot sample of patients undergoing revision shoulder arthroplasty. METHODS: Eighteen patients, comprising eight females and nine males with a mean age of 61 years (range 37 years to 81 years) underwent capsular needle biopsy during the work-up of suspected chronic arthroplasty-related glenohumeral infection. Intra-operative tissue samples were taken from a minimum of three regions of the joint capsule during revision surgery. Standard serum indices were obtained. RESULTS: Of 17 patients with possible infection, five had confirmed culture positive infections based on intra-operative biopsies. Of these five patients, four (80%) had positive cultures from fluoroscopic capsular needle biopsy, with matching cultures. There were no complications. No culture-positive patients had elevated serum indices for infection. CONCLUSIONS: The technique for fluoroscopic capsular needle biopsy appears to be feasible and the preliminary results for this technique appear to be promising, with a sensitivity of 80% and a specificity of 100%.Level of evidence: Level II: diagnostic test.

A randomized, double-blind sham-controlled trial on the efficacy of arthroscopic tennis elbow release for the management of chronic lateral epicondylitis.

BACKGROUND: Tennis elbow is a common elbow pathology typically affecting middle-aged individuals that can lead to significant disability. Most cases resolve within 2 years of symptom onset, but a subset of patients will develop persistent symptoms despite appropriate conservative management. There are several surgical approaches used to treat chronic tennis elbow, with arthroscopic surgery becoming an increasingly popular approach to address this pathology in North America. This procedure involves the arthroscopic release of the extensor carpi radialis brevis tendon (ECRB) origin at the elbow. The potential benefit of arthroscopic treatment of this condition is improved patient outcomes and shorter recovery time following surgery. The results of this technique have been reported only in the context of case series, which have shown positive results. However, in order to justify its widespread use and growing popularity, a high level of evidence study is required. The purpose of this prospective, randomized sham-controlled trial is to determine whether arthroscopic tennis elbow release is effective at treating chronic lateral epicondylitis. METHODS: We will conduct a prospective single center, double-blind, randomized sham-controlled parallel arm trial evaluating the efficacy of arthroscopic tennis elbow release in adult patients with symptoms for at least 6 months. Patients will undergo intraoperative randomization after diagnostic arthroscopy of the elbow to receive either ECRB release (through the creation of a lateral portal) or a sham lateral portal and no ECRB release. The primary outcome will be the Mayo Elbow Performance Score (MEPS) at 1 year follow-up. Secondary outcomes will be the abbreviated Disability of the Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons elbow (ASES-e) score and grip strength at 3, 6, 12 and 24 months as well as return-to-work time, ability to return to full duty and adverse outcomes. DISCUSSION: Results of this study will provide empirical high quality evidence to guide clinical decision-making in patients with chronic tennis elbow. TRIAL REGISTRATION: NCT02236689 (September 8, 2014).

Rotator cuff fatty infiltration and atrophy are associated with functional outcomes in anatomic shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty provides reliable pain relief and restoration of function. However, the effects of fatty infiltration and atrophy in the supraspinatus and infraspinatus muscles on functional outcomes are not well understood. QUESTIONS/PURPOSES: The purposes of this study were to (1) compare preoperative with postoperative fatty infiltration and atrophy of the supraspinatus and infraspinatus muscles after primary shoulder arthroplasty; and (2) identify any associations between these variables and outcome measures. METHODS: A retrospective analysis was undertaken of 62 patients with a mean age of 67 years (range, 34-90 years) who underwent shoulder arthroplasty. CT scans were conducted preoperatively and at 12 months postoperatively. Outcome variables included the degree of supraspinatus and infraspinatus fatty infiltration (percent fatty infiltration and Goutallier grade), muscle area (percent muscle area and Warner atrophy grade), shoulder strength, and the Western Ontario Osteoarthritis Score (WOOS), American Shoulder and Elbow Surgeons score, and Constant outcome score. RESULTS: Preoperatively, the mean percent fatty infiltration (FI) within the supraspinatus and infraspinatus was identical at 14%. One year after shoulder arthroplasty, both muscles had less fatty infiltration (6% and 7%, respectively; p<0.001). Similarly, the Goutallier grade significantly improved postoperatively for the supraspinatus (p=0.0037) and infraspinatus (p=0.0007). Conversely, measures of muscle atrophy remained unchanged postoperatively (p>0.251). Preoperatively, greater supraspinatus percent FI was negatively associated with preoperative shoulder strength (r=0.37, p=0.001) and Constant score (r=0.38, p=0.001). Postoperative infraspinatus percent FI was negatively associated with postoperative strength (r=0.3, p=0.021) and Constant score (r=0.3, p=0.04). Multivariable regression analysis of possible predictive factors demonstrated that preoperative supraspinatus percent muscle area (p=0.016) and the diagnosis of osteoarthritis (p=0.017) were associated with better followup WOOS scores, and preoperative supraspinatus strength was associated with postoperative strength (p=0.0024). Higher degrees of preoperative percent FI were not associated with worse patient-reported outcomes postoperatively. CONCLUSIONS: Supraspinatus and infraspinatus fatty infiltration improves after shoulder arthroplasty, whereas muscle area remains unchanged. Although further study of these variables is required, the negative associations identified between preoperative supraspinatus atrophy and the diagnosis of rheumatoid arthritis and postoperative quality-of-life outcome scores may aid the clinician in selecting the best treatment option for glenohumeral arthrosis and in the management of patient expectations. LEVEL OF EVIDENCE: Level III, prognostic study.

The return of subscapularis strength after shoulder arthroplasty.

BACKGROUND: During shoulder arthroplasty, the subscapularis tendon is released and repaired. Whether subscapularis strength subsequently returns to normal is poorly understood. This study's purpose was to determine whether subscapularis strength returns to normal after shoulder replacement and whether any preoperative factors predict the return of strength postoperatively. METHODS: Sixty-four patients underwent unilateral shoulder arthroplasty. Subscapularis strength was compared between the surgical and contralateral (normal) limbs at baseline (preoperatively) and follow-up. In addition, operative arm subscapularis strength recovery was compared with ipsilateral supraspinatus strength recovery. Independent variables were assessed for their effect on subscapularis strength, including sex, age, dominant-side surgery, preoperative strength, preoperative external rotation, subscapularis management technique, and fatty infiltration. RESULTS: The mean subscapularis strength ratio at 24 months from baseline was 1.19 ± 2.23 (P = .0007). The normal side was significantly stronger than the operative side at all time points (P < .0001). The operative-side subscapularis mean strength ratio was 0.54 ± 0.28 of normal at baseline and 0.70 ± 0.24 at 24 months. Defining normal strength as ±15%, 15% of patients were normal at baseline up to 22% at 24 months. At 24 months, the mean supraspinatus strength ratio from baseline (3.13 ± 6.11) was significantly greater than the subscapularis mean strength ratio (P = .0007). Multivariable regression analysis did not demonstrate any correlation (P > .05) between the independent variables studied and final subscapularis strength. DISCUSSION: Although significant strength improvement from baseline was observed at 2 years after shoulder arthroplasty, subscapularis strength returned to normal in only a minority of patients. Potential prognostic variables associated with final subscapularis strength remain elusive.

Coracoid process x-ray investigation before Latarjet procedure: a radioanatomic study.

BACKGROUND: The purpose of this study was to determine whether a preoperative radiologic assessment of the coracoid process is predictive of the amount of bone available for coracoid transfer by the Latarjet procedure. MATERIAL: Thirty-five patients with anterior instability undergoing a Latarjet procedure were included. A preoperative radiologic assessment was performed with the Bernageau and true anteroposterior (true AP) views. METHODS: The length of the coracoid process was measured on both radiographic views and the values were compared with the length of the bone block during surgery. Statistical analysis was carried out by ANOVA and Wilcoxon tests (P < .05). RESULTS: On radiologic examination, the mean coracoid process length was 29 ± 4 and 33 ± 4 mm on the Bernageau and true AP views, respectively. The mean bone block length during surgery was 21.6 ± 2.7 mm. A significant correlation was found (P = .032) between the coracoid process length on the true AP view and the intraoperative bone block length. DISCUSSION: Preoperative planning for the Latarjet procedure, including graft orientation and screw placement, requires knowledge of the length of coracoid bone available for transfer. This can be facilitated with the use of preoperative standard radiographs, thus avoiding computed tomography. This planning allows the detection of coracoid process anatomic variations or the analysis of the remaining part of the coracoid process after failure of a first Latarjet procedure to avoid an iliac bone graft. CONCLUSION: Radiologic preoperative coracoid process measurement is an easy, reliable method to aid preoperative planning of the Latarjet procedure in primary surgery and reoperations.

Healing rates and subscapularis fatty infiltration after lesser tuberosity osteotomy versus subscapularis peel for exposure during shoulder arthroplasty.

BACKGROUND: Controversy exists regarding the optimal technique of subscapularis mobilization during shoulder arthroplasty. The purpose of this study was to compare healing rates and subscapularis fatty infiltration in patients undergoing a lesser tuberosity osteotomy (LTO) versus subscapularis peel for exposure during shoulder arthroplasty. MATERIALS AND METHODS: Eighty-seven patients, with a mean age of 67.8 ± 10.9 years, undergoing shoulder arthroplasty, were randomized to receive either an LTO (n = 43) or peel (n = 44). Computed tomography scans were conducted preoperatively and at 12 months postoperatively. Outcome variables included healing rates and subscapularis Goutallier fatty infiltration grade, as well as subscapularis strength and Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons outcome scores. RESULTS: Computed tomography imaging was available in 91% (n = 79) of the cohort. The healing rates for the peel (100%) and for the LTO (95%) did not differ significantly (P = .493). Preoperatively, the mean fatty infiltration grade for the peel (mean, 0.53) was not significantly different (P = .925) from the LTO (mean, 0.54). Postoperatively, the Goutallier mean fatty infiltration grade for the peel (mean, 0.95) did not differ significantly (P = .803) from the LTO (mean, 0.9). A significant increase in subscapularis fatty infiltration grade occurred postoperatively from the preoperative status (peel, P = .003; LTO, P = .0002). No statistically significant associations were observed between postoperative fatty infiltration grades and subscapularis strength, Western Ontario Osteoarthritis of the Shoulder Index scores, or American Shoulder and Elbow Surgeons scores. DISCUSSION: No statistically significant differences were observed in the healing rates or subscapularis fatty infiltration grades between the peel and the LTO. This trial does not show any clear difference in radiologic and clinical outcomes of one subscapularis management technique over the other.

A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair.

BACKGROUND: Controversy exists regarding the optimal technique for arthroscopic rotator cuff repair. The purpose of this multicenter, randomized, double-blind controlled study was to compare the functional outcomes and healing rates after use of single-row and double-row suture techniques for repair of the rotator cuff. METHODS: Ninety patients undergoing arthroscopic rotator cuff repair were randomized to receive either a single-row or a double-row repair. The primary objective was to compare the Western Ontario rotator cuff index (WORC) score at twenty-four months. Secondary objectives included comparison of the constant and american shoulder and elbow surgeons (ASES) scores and strength between groups. Anatomical outcomes were assessed with magnetic resonance imaging (MRI) or ultrasonography to determine the postoperative healing rates. RESULTS: Baseline demographic data including age (p = 0.29), sex (p = 0.68), affected side (p = 0.39), and rotator cuff tear size (p = 0.28) did not differ between groups. The WORC score did not differ significantly between groups at any time point (p = 0.48 at baseline, p = 0.089 at three months, p = 0.52 at six months, p = 0.83 at twelve months, and p = 0.60 at twenty-four months). The WORC score at each postoperative time point was significantly better than the baseline value. The Constant score, ASES score, and strength did not differ significantly between groups at any time point. Logistic regression analysis demonstrated that a smaller initial tear size and double-row fixation were associated with higher healing rates. CONCLUSIONS: No significant differences in functional or quality-of-life outcomes were identified between single-row and double-row fixation techniques. A smaller initial tear size and a double-row fixation technique were associated with higher healing rates as assessed with ultrasonography or MRI. LEVEL OF EVIDENCE: Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Comparison of lesser tuberosity osteotomy to subscapularis peel in shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Controversy exists regarding the optimal technique of subscapularis tendon mobilization during shoulder arthroplasty. The purpose of the present randomized double-blind study was to compare two of these techniques-lesser tuberosity osteotomy and subscapularis peel-with regard to muscle strength and functional outcomes. METHODS: Patients undergoing shoulder arthroplasty were randomized to undergo either a lesser tuberosity osteotomy or a subscapularis peel. The primary outcome was subscapularis muscle strength as measured with an electronic handheld dynamometer at twenty-four months postoperatively. Secondary outcomes included the Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons scores. A sample size calculation determined that eighty-six patients provided 90% power with a 0.79 effect size to detect a significant difference between groups. RESULTS: Forty-three patients were allocated to subscapularis osteotomy, and forty-four patients were allocated to subscapularis peel. Eighty-three percent of the study cohort returned for the twenty-four-month follow-up. The primary outcome of subscapularis muscle strength at twenty-four months revealed no significant difference (p = 0.131) between the lesser tuberosity osteotomy group (mean [and standard deviation], 4.4 ± 2.9 kg) and the subscapularis peel group (mean, 5.5 ± 2.6 kg). Comparison of secondary outcomes, including the Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons scores, demonstrated no significant differences between groups at any time point. Compared with baseline measures, mean subscapularis muscle strength, Western Ontario Osteoarthritis of the Shoulder Index score, and American Shoulder and Elbow Surgeons score all improved significantly in both groups at twenty-four months (p < 0.001). DISCUSSION: No significant differences in the primary or secondary outcomes of function were identified between the lesser tuberosity osteotomy group and the subscapularis peel group. For the parameters investigated, this trial does not demonstrate any clear advantage of one subscapularis treatment technique over the other.

The anatomy of the superior labrum and biceps origin in the fetal shoulder.

The presence of a sublabral recess has been observed in adult shoulders. It is unclear whether this occurrence is a developmental variation or is acquired. The primary objective of the study was to determine if a cleft exists between the superior labrum and the superior cartilaginous glenoid anlage during the second trimester. The secondary objective was to define the origin of the long head of the biceps in the human fetus in the second trimester. Shoulders of 11 fetuses, 11-20 weeks old, were sectioned in the coronal plane. The superior labrum was observed to be continuous with the superior glenoid anlage, and a cleft was not observed at any stage of development. The biceps tendon originated from the superior labrum and the superior glenoid tubercle anlage in all specimens. Fibers extending in the direction of superior glenoid tubercle anlage were always very prominent.